Dental Public Dental Public Health Health

Considerations for Considerations for Prison PopulationsPrison Populations

Nicholas S. Makrides DMD, MA, MPHNicholas S. Makrides DMD, MA, MPH

CAPT, USPHSCAPT, USPHS

Slides Provided by Jay D. Shulman, DMD, MA, Slides Provided by Jay D. Shulman, DMD, MA, MSPHMSPH

Correctional Systems in the Correctional Systems in the

United StatesUnited States Characterized by fragmentationCharacterized by fragmentation Prison – Prison –

Federal Bureau of Prisons (10%)Federal Bureau of Prisons (10%) Individual state and territorial prisonsIndividual state and territorial prisons

JailJail Federal Bureau of PrisonsFederal Bureau of Prisons CountyCounty

ObjectivesObjectives Describe “public health approach” to Describe “public health approach” to

correctional dentistrycorrectional dentistry Demographics of incarcerated Demographics of incarcerated

‘community’‘community’ Discuss the absence of published studiesDiscuss the absence of published studies Describe the oral health needs of inmatesDescribe the oral health needs of inmates Provide recommendations for developing Provide recommendations for developing

a correctional dentistry research agendaa correctional dentistry research agenda

Dental Public HealthDental Public Health

Focus is community, rather than individualFocus is community, rather than individual Community: Community: a group with diverse a group with diverse

characteristics linked by social ties, characteristics linked by social ties, common perspectives, or geographycommon perspectives, or geography. .

A prison or correctional system is a A prison or correctional system is a community in public health sensecommunity in public health sense

As correctional dentists, this is your As correctional dentists, this is your communitycommunity

Public Health versus Clinical Paradigms

Problems Common to all Problems Common to all Public Health Clinics and Public Health Clinics and

SettingsSettings Limited ResourcesLimited Resources

Inadequate fundingInadequate funding Dental budgets often subsumed in medical budgets Dental budgets often subsumed in medical budgets

Tremendous Oral Health NeedTremendous Oral Health Need Periodontal disease Periodontal disease High caries rateHigh caries rate

Professional StaffingProfessional Staffing Salaries are not competitiveSalaries are not competitive Economic incentives of private practice are alluringEconomic incentives of private practice are alluring Dentists do not want to work in a prisonDentists do not want to work in a prison Support staff hard to recruitSupport staff hard to recruit

Models of Dental CareModels of Dental Care

Free-Market ModelFree-Market Model Unconstrained resourcesUnconstrained resources Private practicePrivate practice Preservation and Preservation and

restoration of natural restoration of natural teethteeth

Cost not a factorCost not a factor Implants, posterior endo, Implants, posterior endo,

C&B, cosmetic C&B, cosmetic restorationsrestorations

Maximize individual’s Maximize individual’s oral healthoral health

Institutional ModelInstitutional Model Constrained resourcesConstrained resources Military, community Military, community

health centers, prisons / health centers, prisons / jailsjails

Preservation and Preservation and maintenance of oral maintenance of oral healthhealth

Cost-effectivenessCost-effectiveness Not all missing teeth Not all missing teeth

replacedreplaced Maximize community’s Maximize community’s

oral healthoral health

Considerations for Delivery Considerations for Delivery of Careof Care

Standard of care must be establishedStandard of care must be established Care must be prioritized Care must be prioritized

Classification systemClassification system Populations targetedPopulations targeted

Prevention modelsPrevention models Oral Hygiene Instruction (OHI)Oral Hygiene Instruction (OHI) Use of fluorides (NaF)Use of fluorides (NaF)

Atraumatic Restorative Technique Atraumatic Restorative Technique (ART)(ART)

Demographics Demographics

Understanding your Patient Understanding your Patient Population Population

U.S. Prison and Jail U.S. Prison and Jail CensusCensus

The BreakdownThe Breakdown Total incarcerated: 2,267,787 Total incarcerated: 2,267,787 Federal & state prisons: 1,421,911 (62.7%)Federal & state prisons: 1,421,911 (62.7%)

State and federal inmates held in local jails: State and federal inmates held in local jails: 74,378 74,378

Local jails: 713,990 (31.5%)Local jails: 713,990 (31.5%) Juvenile facilities: 102,338 Juvenile facilities: 102,338 US Territory prisons: 15,757 US Territory prisons: 15,757 Homeland Security facilities: 9,788 Homeland Security facilities: 9,788 Military prisons: 2,177 (excluding Military prisons: 2,177 (excluding

Guantánamo)Guantánamo) Indian country jails: 1,826 Indian country jails: 1,826

Inmates by RaceInmates by Race

Source: Bureau of Justice Statistics

Inmates by GenderInmates by Gender

Source: Bureau of Justice Statistics

Impact of DemographicsImpact of Demographics

Large proportion of low-SES inmatesLarge proportion of low-SES inmates Large minority populationLarge minority population High prevalence of chronic disease High prevalence of chronic disease

Diabetes, HIV associated with periodontal Diabetes, HIV associated with periodontal and mucosal diseaseand mucosal disease

Graying population Graying population ↑ oral cancer risk↑ oral cancer risk High prevalence of mentally illHigh prevalence of mentally ill Large unmet oral health needs based Large unmet oral health needs based

on anecdotal evidence and limited on anecdotal evidence and limited studies studies

Published Published StudiesStudies

NHANES Target NHANES Target PopulationPopulation

Total US civilian, Total US civilian, non-institutionalizednon-institutionalized populationpopulation

Surgeon General’s Surgeon General’s ReportReport

The Invisible PopulationThe Invisible Population

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

Oral Health in America: A Report of the Oral Health in America: A Report of the Surgeon GeneralSurgeon General acknowledged acknowledged importance of characterizing oral health importance of characterizing oral health needs but stated that data were needs but stated that data were insufficient or lackinginsufficient or lacking

No No Healthy People 2010Healthy People 2010 oral health oral health objectives for incarcerated populations objectives for incarcerated populations

A Void in Peer-Reviewed A Void in Peer-Reviewed LiteratureLiterature

Correctional dentistry is the Correctional dentistry is the academic backwateracademic backwater 6 papers relating to adults of which only 6 papers relating to adults of which only

three were published after 1977*three were published after 1977* No national reports of inmate health No national reports of inmate health

Not part of the US research agendaNot part of the US research agenda No projects: oral health of incarcerated No projects: oral health of incarcerated

CRISP search CDC and NIDCRCRISP search CDC and NIDCR Robert Wood JohnsonRobert Wood Johnson

*Treadwell HM, Formicola AJ, Am J Public Health. 2005 Oct;95(10):1677-8.

Issues Surrounding Issues Surrounding Inmate CareInmate Care

Unpopular with taxpayers Unpopular with taxpayers Legislators may find it difficult to Legislators may find it difficult to

support inmate programs support inmate programs May lose favor with constituentsMay lose favor with constituents “ “Hug a thug” not good electoral strategyHug a thug” not good electoral strategy

Dental Societies rally around causes that Dental Societies rally around causes that build consensus. “Give a Kid a Smile build consensus. “Give a Kid a Smile Day” Day”

Public health communities often do not Public health communities often do not see prisons as a public health population.see prisons as a public health population.

What is KnownWhat is Known

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

All studies reveal unmet needs All studies reveal unmet needs (caries an periodontal disease)(caries an periodontal disease)

Very few studies follow a cohort Very few studies follow a cohort longitudinally to investigate longitudinally to investigate preventative or intervention efforts.preventative or intervention efforts.

Why is Conducting Why is Conducting Research Research DifficultDifficult

Research is a low priority for most clinical Research is a low priority for most clinical dentistsdentists

Coordinating efforts is often cumbersomeCoordinating efforts is often cumbersome Reliability of data is often questionableReliability of data is often questionable Inmates are mobile throughout the systemInmates are mobile throughout the system IRB will not permit clinical studiesIRB will not permit clinical studies Very few public health trained dentists Very few public health trained dentists

working in correctionsworking in corrections

Raising Raising AwarenessAwareness

METH MOUTHMETH MOUTH

jshulman

The background needs to be fixed

Thinking Out of The BoxThinking Out of The Box

“Never, ever think outside the box.”

National National RecommendationsRecommendations

NHANES for institutionalized populationsNHANES for institutionalized populations Inclusion of institutionalized populations in Inclusion of institutionalized populations in

2010 and 2020 initiatives2010 and 2020 initiatives Better working relationships with state Better working relationships with state

dental directors and DOC dental directors dental directors and DOC dental directors Inclusion of oral health within the overall Inclusion of oral health within the overall

general health of inmates being released general health of inmates being released Establish level of care standards for Establish level of care standards for

correctional dentistrycorrectional dentistry

National National RecommendationsRecommendations

Partner with academic institutions Partner with academic institutions with strong Public Health programs with strong Public Health programs (Shulman @ Baylor)(Shulman @ Baylor)

Increase the number of public health Increase the number of public health practitionerspractitioners

Develop a fellowship in correctional Develop a fellowship in correctional dentistrydentistry

Increase the IT infrastructure to Increase the IT infrastructure to include electronic health recordsinclude electronic health records

Electronic Medical/Dental Electronic Medical/Dental RecordsRecords

Assessing the problemAssessing the problem Collect accurate baseline data at intakeCollect accurate baseline data at intake

DMFTDMFT CPITNCPITN Soft Tissue and Oral Cancer ExaminationsSoft Tissue and Oral Cancer Examinations

The Electronic Health Record.The Electronic Health Record. Realtime DATARealtime DATA Longitudinal StudiesLongitudinal Studies Information about accessInformation about access Waiting timesWaiting times Access to medical conditions that may be Access to medical conditions that may be

confoundersconfounders

Transitioning Inmates into Transitioning Inmates into SocietySociety

Individual’s constitutional right to Individual’s constitutional right to dental care stops the day he leaves dental care stops the day he leaves prisons (unique to US)prisons (unique to US)

No safety nets for adult dental care No safety nets for adult dental care In US dentistry is a luxury good In US dentistry is a luxury good The last opportunity for consistent The last opportunity for consistent

dental care is in prisonsdental care is in prisons

Legal BasisLegal Basis

Courts have held that institutions Courts have held that institutions that show that show deliberate indifferencedeliberate indifference to to serious medical needsserious medical needs of inmates of inmates violate inmates’ right to be free from violate inmates’ right to be free from “cruel and unusual punishment” “cruel and unusual punishment” guaranteed by Amendment VIII of guaranteed by Amendment VIII of the US Constitution.the US Constitution. Estelle v. GambleEstelle v. Gamble (1976) (1976)

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

MSPHMSPH

““The degree of civilization in The degree of civilization in a society can be judged by a society can be judged by

entering its prisons.” entering its prisons.”

Dostoyevsky Dostoyevsky