1. Dental Public Health Considerations for Prison Populations Nicholas S. Makrides DMD, MA, MPH CAPT, USPHS Slides Provided by Jay D. Shulman, DMD, MA, MSPH

2. Correctional Systems in the United States Characterized by fragmentation Characterized by fragmentation Prison – Prison – Federal Bureau of Prisons (10%) Federal Bureau of Prisons (10%) Individual state and territorial prisons Individual state and territorial prisons Jail Jail Federal Bureau of Prisons Federal Bureau of Prisons County County

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

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

5. Public Health versus Clinical Paradigms

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

7. Models of Dental Care Free-Market Model Unconstrained resources Unconstrained resources Private practice Private practice Preservation and restoration of natural teeth Preservation and restoration of natural teeth Cost not a factor Cost not a factor Implants, posterior endo, C&B, cosmetic restorations Implants, posterior endo, C&B, cosmetic restorations Maximize individual’s oral health 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

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

9. Demographics Understanding your Patient Population

10. U.S. Prison and Jail Census

11. The 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: 74,378 State and federal inmates held in local jails: 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 Guantánamo) Military prisons: 2,177 (excluding Guantánamo) Indian country jails: 1,826 Indian country jails: 1,826

12. Inmates by Race Source: Bureau of Justice Statistics

13. Inmates by Gender Source: Bureau of Justice Statistics

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

15. Published Studies

16. NHANES Target Population Total US civilian, non-institutionalized population

17. Surgeon General’s Report

18. The Invisible Population Usual sources of national oral health data (NHANES, BRFSS) exclude the institutionalized 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 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 No Healthy People 2010 oral health objectives for incarcerated populations

19. A Void in Peer-Reviewed Literature Correctional dentistry is the academic backwater Correctional dentistry is the academic backwater 6 papers relating to adults of which only three were published after 1977* 6 papers relating to adults of which only three were published after 1977* No national reports of inmate health No national reports of inmate health Not part of the US research agenda Not part of the US research agenda No projects: oral health of incarcerated No projects: oral health of incarcerated CRISP search CDC and NIDCR CRISP search CDC and NIDCR Robert Wood Johnson Robert Wood Johnson *Treadwell HM, Formicola AJ, Am J Public Health. 2005 Oct;95(10):1677-8.

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

21. What is Known There are approximately 15 known studies describing the prevalence of disease within prison populations. There are approximately 15 known studies describing the prevalence of disease within prison populations. All studies reveal unmet needs (caries an periodontal disease) All studies reveal unmet needs (caries an periodontal disease) Very few studies follow a cohort longitudinally to investigate preventative or intervention efforts. Very few studies follow a cohort longitudinally to investigate preventative or intervention efforts.

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

23. Raising Awareness

24. METH MOUTH

26. Thinking Out of The Box “Never, ever think outside the box.”

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

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

29. Electronic Medical/Dental Records Assessing the problem Assessing the problem Collect accurate baseline data at intake Collect accurate baseline data at intake DMFT DMFT CPITN CPITN Soft Tissue and Oral Cancer Examinations Soft Tissue and Oral Cancer Examinations The Electronic Health Record. The Electronic Health Record. Realtime DATA Realtime DATA Longitudinal Studies Longitudinal Studies Information about access Information about access Waiting times Waiting times Access to medical conditions that may be confounders Access to medical conditions that may be confounders

30. Transitioning Inmates into Society Individual’s constitutional right to dental care stops the day he leaves prisons (unique to US) Individual’s constitutional right to dental care stops the day he leaves 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 dental care is in prisons The last opportunity for consistent dental care is in prisons

31. 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. 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) Estelle v. Gamble (1976)

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

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