International Dental Journal 2012; 62: 27–32

doi: 10.1111/j.1875-595X.2011.00082.x

A survey on oral health status and treatment needs oflife-imprisoned inmates in central jails of Karnataka, India

Veera Reddy, Chadlavda Venkanta Kondareddy, Sunitha Siddanna and Murya Manjunath

Department of Public Health Dentistry, JSS Dental College and Hospital, A Constituent College of JSS University, Mysore, India.

Background: The prison population is a unique and challenging one with many health problems, including poor oral health.In a developing country like India, oral health problems of the prisoners had received scant attention. Objectives: To assessthe oral health status and treatment needs of life imprisoned inmates and to know the existing oral health care facilitiesavailable in central jails of Karnataka. Materials and methodology design: Cross sectional survey Participants: Asystematically selected sample of 800 life imprisoned inmates, were interviewed and examined using modified WHO oralhealth assessment proforma (1997). Results: The prevalence of caries was 97.5% mean Decayed Missing FilledTeeth(DMFT) was 5.26; Majority of the study population had Community Periodontal Index(CPI) score of 2, whereas21.6% had at least one sextant with a CPI score of 4. 41.1% prisoners were severely affected with loss of attachment. 8.8%inmates had dentures. Oral sub mucous fibrosis was observed among 9.9% of prisoners. 97.4% of the subjects needed oralhygiene instruction, 87.6% needed restoration, 62.1% extraction of teeth and 32.2% needed prosthesis. Bangalore andMysore central jail had oral health care facilities on regular basis. Conclusion: This study emphasises the need for specialattention from government and voluntary organisations to improve the oral health of inmates.

Key words: Dental care, dental caries, jails, oral health status, periodontal diseases, prisoners, survey

INTRODUCTION

The prison population is unique and challenging withmany health problems, including poor oral health.Dental diseases can reach epidemic proportions in theprison setting1. Many challenges exist in deliveringservices in the prison system, including service provi-sion with respect to security procedures, recruitmentand retention of dental staff in relation to strongdemand and lucrative remuneration for dentists inprivate practice. There is currently no standardisedsystem of assessment and prioritisation of the dentalneeds of prisoners2.

The health of prisoners is of great concern, particu-larly because the number of persons under the jurisdic-tion of correction systems, including those on probationor parole, continues to increase dramatically. It isgenerally acknowledged from extensive research thatcorrectional populations are more vulnerable to a widerange of health problems, most commonly alcoholism,drug abuse, infectious diseases, chronic illnesses, mentalillnesses, and psychosocial and psychiatric problems3.

Prisoners serving long-term or life sentences oftenexperience differential treatment and worse conditions

of detention relative to other categories of prisoner.Their conditions of detention, compounded by theindeterminate nature of their sentences, often have aprofound sociological and psychological impact, whichnegates the rehabilitative purpose of punishment.

Hardly any health professionals choose to work inthe prison system. A lack of health concern, facilitiesand expertise further deteriorates the health of inmates.This explains the reason for such limited studiesconducted in the prison system, especially in India4.Several studies have reported higher prevalence ofdental caries and periodontal diseases among incarcer-ated individuals4–16. However, Clare5 reported asubstantial reduction in the prevalence of dental cariesand an improvement in periodontal health amongprisoners who had served continually for 3 years inprison.

In a developing country, such as India, the oral healthproblems of prisoners have received little attention. Asthe information is sparse, the objectives of the presentstudy were to identify the oral health problems of life-imprisoned inmates and to determine the existing oralhealthcare facilities available in the central jails ofKarnataka.

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O R I G I N A L A R T I C L E

METHODOLOGY

A cross-sectional study was conducted from October2009 to March 2010 in seven central jails of Karnataka,India, following ethical approval from the EthicalClearance Committee of JSS Dental College andHospital, Mysore, India. Written consent was obtainedfrom the inmates.

Sampling

The total prison population for Karnataka in 2009 was13,216, consisting of 12,664 (95.8%) males and 552(4.2%) females; 3200 inmates were serving life impris-onment in seven central jails of Karnataka (2009). Thesample size was calculated using the online sample sizecalculator, available at http://www.surveysystem.com;the sample required for a finite population of 3200, aconfidence interval of three and a confidence level of95% was 800.

For a population of 3200, the required sample was800, i.e. 25% of the population was selected. Gender-wise there were 2880 males and 320 females, 800 (722males and 78 females) of whom responded. Thesamples were selected proportionately from each jaildepending on the target population (those who hadbeen life imprisoned for at least 3 years). The samplinginterval (n) was calculated by dividing the targetpopulation on the day of sampling by the sample size.All possible participants (3200) were listed and num-bered. A start number was chosen at random and everyfifth number was picked thereafter. If a potentialparticipant was selected, but declined to take part, thenext available number was substituted.

Training and calibration

The investigator was trained for the diagnosis of oraldiseases and calibrated in the interpretation of indicesunder the guidance of a senior faculty member.Agreement for assessment was 90%.

Collection of data

The data collection process involved the escort of theselected prisoners in groups to the interview by twonumberdaras (prisoners with good behaviour). Thenumberdaras offered reassurance to the participantsabout their anonymity. Each prisoner was individuallyinterviewed and examined, and was asked to return to thecell block on completion of the examination. Eachinterviewandexaminationlastedbetween10and15 min.

The survey design was two-fold:• Questionnaire. The study involved the completion

of a predesigned questionnaire which containedquestions on general information, tobacco con-

sumption, oral hygiene practices, imprisonmentcharacteristics, such as sentence category and dura-tion spent, and the availability and utilisation ofdental healthcare facilities

• Oral examination of inmates. The inmates wereasked to sit comfortably on a chair in a well-ventilated room and clinical examination wascarried out under natural light with a mouth mirror,explorer and community periodontal index (CPI)probe [American Dental Association (ADA), TypeIII, examination method]. Instruments had beenautoclaved previously in cloth wrapping in the jailhospital, when taken to barricade cold method ofsterilisation was followed, using aldehyde-freeinstrument disinfectant (Korsolex� AF, Bode Che-mie Hamburg, Hamburg, Germany) at 6% for5 min, as no self-sealing pouches were provided.The data were recorded by the investigator on aprinted Modified World Health Organization OralHealth Assessment Form (1997)17. The OralHygiene Index-Simplified (OHI-S) of Greene andVermillion18 was used to record the oral hygienestatus.

Statistical analysis

The data were then entered manually into the com-puter, tabulated and analysed. The Statistical Packagefor Social Sciences (SPSS) version 16 was used. Thevarious tests used for analysis were the arithmeticmean, standard deviation, chi-squared test, analysis ofvariance (ANOVA) and contingency coefficient.P < 0.05 was taken to be statistically significant forthe purpose of analysis.

RESULTS

Eight hundred prisoners were interviewed and clinicalexamination was performed in seven central jails ofKarnataka; 90.3% were males and 9.7% were females.The mean age of the participants was 41.25 years (19–76 years), a large percentage (80.8%) were married andonly 2.1% had a postgraduate education. The meanduration of imprisonment served was 6.14 years (3–15 years) (Table 1).

Tobacco consumption

The percentage of prisoners who smoked was 72.5%,59.1% of whom smoked ‘beedi’ (‘bidi’) (a thin SouthAsian cigarette filled with tobacco flake and wrapped ina tendu leaf tied with a string at one end), 7.5%cigarettes and 5.9% both beedi and cigarettes; 53.4%of prisoners chewed tobacco, 27.6% of whom weretobacco chewers and 25.8% of whom used ‘gutkha’ [apreparation of crushed areca nut (also called betel nut),

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tobacco, catechu, paraffin, lime and sweet or savouryflavourings]. Overall, 38.8% of prisoners both smokedand chewed tobacco (Figure 1).

Oral health-related behaviour

Sixty-one per cent of prisoners (n = 495) claimed tohave visited the dentist for various dental problems.The younger age group had visited the dentist for thetreatment of decay (40.4%), whereas the older agegroup had visited the dentist for the treatment of mobileteeth (41.3%); this association was found to be

statistically very highly significant (P < 0.001) Withregard to their oral hygiene practices, 66.6% used atoothbrush, 29% used a finger and 4.4% used otheraids to clean their teeth.

Types of dental services used

Forty-eight per cent (n = 236) used dental services forpain, swelling and infection, and only 3.6% of inmatesreceived replacement of teeth (Figure 2). The enquiryreports of the jail superintendents revealed that Banga-lore and Mysore central jails had part-time visits ofdentists and permanent dental healthcare facilities forthe treatment of prisoners, respectively; however, nosuch facilities existed in any other central jails ofKarnataka.

Mucosal health

A total of 20.5% of inmates had oral mucosal lesions.Among these lesions, oral submucous fibrosis (OSMF)was found in 9.9% of inmates, 7% had ulcers and1.1% had leucoplakia; the difference between healthymucosa and affected lesions was found to be highlysignificant (P < 0.001). It was found that inmates ofDharwad, Gulbarga and Belgaum central jails hadhigher percentages of OSMF (16.7%, 14.6% and13.5%, respectively).

Periodontal status

Despite reporting good oral hygiene practices, 66.3%of prisoners had poor oral hygiene status; 39.3% had aCPI score of two and 48.6% had a CPI score of three orfour; 30.1% of prisoners had a loss of attachment(LOA) score of one or two (more than 4 mm) and 1.7%of prisoners had a score of four.

Dentition status

A total of 92.5% of prisoners had one or moreuntreated decayed (D) teeth, 57.1% had one or moremissing (M) teeth and 24.6% had one or more filled (F)

Table 1 Demographics of the study population

Characteristics n Percentage Mean ± SD

PlaceBelgaum 148 18.5Bijapur 51 6.4Dharwad 30 3.8Bellary 63 7.9Bangalore 282 35.2Gulbarga 103 12.8Mysore 121 15.4

GenderMale 722 90.3Female 78 9.7

Age groups (years)18–24 169 21.1 41.25 ± 12.2525–34 267 33.435–44 186 23.345–54 115 14.4>54 63 7.9

Marital statusUnmarried 100 12.5Married 647 80.8Divorced 22 2.8Widower 22 2.8Widow 9 9.1

Education levelIlliterate 293 36.6Primary education 233 29.3Secondary education 166 20.8PUC 47 5.9Graduate 44 5.4Postgraduate 17 2.1

Length of imprisonment (years)3–6 467 58.4 6.14 ± 2.257–10 296 37.011–15 37 4.6

PUC, Pre-University Course.

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Status Mode StatusParameters

Type Smoke + Chew

Smokers Bidi Cigarette Both Nonchewers

Chewers Tobaccochewing

Gutkha Bothchew

Figure 1. Distribution of inmates according to tobacco habits.

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Figure 2. Dental treatments received by inmates according to theduration of imprisonment.

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Oral health status and treatment needs of life-imprisoned inmates

teeth. The mean DMFT score was 5.26 (± 2.91)(Figure 3).

Need for treatment

A total of 48.1% of the inmates needed one surfacefilling, 39.5% required two or more surface fillings,9.4% needed crown and bridge, 59.2% needed pulpcare and 62.1% needed extraction (Figure 4); 97.7% ofthe study participants required oral hygiene instruc-tions, 48.1% required complex periodontal treatmentsand 32.0% required prostheses.

Prosthetic status and needs

Among the prisoners examined, 8.8% had prostheses inthe upper and lower jaws (6.6% and 2.2%, respectively).The most commonly used prosthesis was removablepartial dentures. The percentage of inmates wearingprostheses was greater in the 25–34-year age group(Figure 5). Prisoners who had served imprisonment for11–15 years had higher percentages of prosthetic need(22.8% for upper jaw and 19.6% for lower jaw) in theform of multiunit prostheses. The need for prostheseswas higher for the upper arch than the lower arch.

Effect of imprisonment on oral health status

The OHI-S, CPI, LOA and DMFT scores more or lessincreased linearly as the length of imprisonment

increased, except for the mean number of decayedteeth (P > 0.05) (Figure 6).

DISCUSSION

The results of this cross-sectional study on life-impris-oned inmates in the central jails of Karnataka provide aunique opportunity to analyse the oral health status inthis group. There have been very few studies carried outon the oral health status of prisoners. Of these, somestudies6–9 have reported that the oral health status ofprison inmates is worse than that of the generalpopulation. The prevalence of dental caries was foundto be 92.5% with a DMFT value of 5.26. Severalstudies3–16 have reported higher values of DMFT. Thismay be a result of differences in the refined dietconsumption of the prisoners in the different studies.

Clare5 observed that there was a substantial reduc-tion in dental caries among prisoners who had been inprison continuously for 3 years. The mean number ofdecayed surfaces was reduced from 6.7 to 3.6 (46.3%reduction). This was a result of the restoration ofdecayed teeth, extraction of hopeless teeth and theavailability and utilisation of dental health services inprison. However, several other studies3–16,19–24 havereported an increase in decayed teeth among prisonerswho have served in prison for 3 years or more. Thiswas attributed to an ignorance about oral diseases,

708090

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Treatment needs

YesNo

One surfa

ce fil

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Two or m

ore surfa

ce fil

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Crown/bridge

Pulp care

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Figure 4. Number and percentages of inmates needing treatment.

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BridgeMore than 1 bridgePartial denture

10

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0Belgaum Bijapur Dharwad Bellary Bangalore

LocationGulbarga Mysore

Figure 5. Number and percentages of inmates with prostheses by typeof prosthesis.

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3-6 yrs

7-10 yrs

11-15 yrs

OHI-S CPI LOA DOral health status

M F DMFT

Figure 6. Oral health status of prisoners according to duration ofimprisonment served. CPI, community periodontal index; D, decayed;

DMFT, decayed, missing and filled teeth; F, filled; LOA, loss ofattachment; M, missing; OHI-S, Oral Hygiene Index-Simplified.

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0Belgaum Bijapur Dharwad Bellary Bangalore

LocationGulbarga Mysore

DMFDMFT

Figure 3. Mean number of teeth decayed (D), missing (M) and filled(F), and mean DMFT scores, among inmates.

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deleterious habits and the nonavailability of dentalhealthcare facilities in prison. These findings were inagreement with our study results.

We observed a large number of missing teeth. Thiswas a result of the extraction of teeth and the fact thatfacilities for the conservation of teeth were not avail-able. Both the numbers of decayed and filled teeth infemales were lower in our study when compared with areport by Heng and Douglas2. Females had a signifi-cantly greater need for filling and extraction of teethrelative to males. This indicates a greater utilisation ofdental health care by males than by females. Theunderutilisation of oral healthcare facilities by femaleinmates may be explained by the fact that femaleinmates may feel insecure in accessing a hospital area inprison which is mostly managed by male inmates; thisapprehension was noted during interviews by theinvestigator. This area should be investigated further,so that a special recommendation can be made to theauthorities.

Oral health behaviour

Our results with respect to smoking habits were inagreement with a study conducted by Dahyia andCroucher23 among male prisoners in Guragon districtjail, Haryana. Some studies12,19,21 have reported ahigher prevalence of smoked tobacco products (ciga-rettes) in both genders. Christina et al.24 reported asignificantly higher smoking prevalence for femaleinmates (81%) relative to male inmates (71%).

The habit of chewing tobacco was found in 28.0%and 24.4% of male and female inmates, respectively.Together with tobacco smoking, a large number ofinmates (42.8%) were habitual tobacco chewers. Theseresults were not in agreement with a study reported byDahyia and Croucher23, who found that only 7.3% ofinmates chewed tobacco and 12.5% both smoked andchewed tobacco. Our results were not in agreement withother studies12,21 with regard to tobacco chewing. Thismay be a result of differences in cultural factors in India.

Some studies12,21 have reported higher percentages ofuse of alcohol and illicit drugs by prisoners. This maybe a result of boredom, relief from stress, peer pressureand ⁄ or a combination of these issues. However, thepresent study did not evaluate the use of alcohol andillicit drugs for obvious reasons. Indian jails prohibitthe use of alcohol and illicit drugs, but there have beenseveral cases in which <1% of inmates have managed toaccess alcohol and illicit drugs.

Periodontal status

A total of 97.7% of inmates required oral hygieneinstructions and oral prophylaxis; 48.6% of inmatesrequired complex periodontal treatment. Similar

results have been reported by Nobil3, who stated that89.5% of inmates required at least oral hygieneinstructions with extremely high needs for prophy-laxis, and 19.7% required complex periodontal treat-ment. The reason for the fewer inmates requiringcomplex treatments compared with our study may bethe presence of regular prison dental services in otherprisons.

Oral mucosal health

A high prevalence of OSMF was observed among theinmates of Dharwad, Gulbarga and Belgaum centraljails. This may be a result of the high prevalence oftobacco habits. The prevalence was also relatively highamong young prisoners. This reflects the high use oftobacco chewing. Ulcers (mucocutaneous lesions) werefound more commonly in older prisoners, which was inagreement with a study conducted by Pedraza et al.25

on alterations in the oral mucosa of prisoners inMexico. It was assumed in this study that a highertendency to use tobacco during free time was mainly aresult of limited freedom of movement and the stressesof loneliness. Hence, the prevalence of oral mucosallesions may increase with an increase in the length ofimprisonment.

Dental health care received during imprisonment

A total of 53.2% of prisoners visited the dentist fordental treatment, the most common complaint beingdecay (34.5%); 36.7% of inmates never visited thedentist and this might have been the result of a lack ofawareness. This finding was in agreement with aprevious study conducted by Heidari et al.21, who foundthat 24% of prisoners never visited the dentist and 69%claimed to have visited the dentist. The perceived needfor dental treatment was high and this may have been aresult of the long waiting lists, part-time services andsecurity reasons within the prison setting, as noted inother studies12,15,21,22. The percentage of inmates whoreceived extraction as treatment was high and very few ofthese inmates received restorations. These observationsdisagree with a study reported by Osborn et al.15. Thisdifference may be attributed to the regular dental servicesin Australian prisons compared with the part-time dentalservices in Karnataka prisons.

CONCLUSION

The present study was conducted on 800 life-impris-oned inmates in the central jails of Karnataka to assesstheir oral health status and treatment needs. It wasobserved that the life-imprisoned inmates who hadserved for longer durations showed a higher percentageof dental caries, periodontal diseases and prosthetic

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Oral health status and treatment needs of life-imprisoned inmates

needs. Oral healthcare facilities were available on aregular basis for the inmates of Bangalore and Mysorecentral jails. This study emphasises the need for specialattention from the government and voluntary organi-sations to meet the oral health needs of this specialgroup. Further longitudinal studies should be con-ducted to explore the relationship between the onsetand progression of dental diseases in the prisonenvironment.

Acknowledgements

Thanks go to the Inspector General of Police (Prison)Bangalore, Director General of the Indian Council ofMedical Research (ICMR), Vice Chancellor of JSSUniversity, Principal of JSS Dental College & Hospital,Mysore, and all participants and postgraduates in ourdepartment for their kind support during this researchwork.

Conflicts of interest

The authors declare that they have no conflicts ofinterest.

Source of support

Indian Council of Medical Research (ICMR) Grant(3 ⁄ 2 ⁄ 09 ⁄ PG THESIS –MPD 16).

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Correspondence to:Dr. Veera Reddy,

Department of Public Health Dentistry,JSS Dental College and Hospital,

A Constituent College of JSS University,Sri Shivarathreeshwara Nagar,

Bannimantap Mysore - 570015,Karnataka,

India.Email: drveera.reddy75@gmail.com

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