oral health of adult populations
TRANSCRIPT
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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
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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
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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
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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
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Public Health versus Clinical Paradigms
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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
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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
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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)
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Demographics Demographics
Understanding your Patient Understanding your Patient Population Population
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U.S. Prison and Jail U.S. Prison and Jail CensusCensus
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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
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Inmates by RaceInmates by Race
Source: Bureau of Justice Statistics
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Inmates by GenderInmates by Gender
Source: Bureau of Justice Statistics
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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
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Published Published StudiesStudies
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NHANES Target NHANES Target PopulationPopulation
Total US civilian, Total US civilian, non-institutionalizednon-institutionalized populationpopulation
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Surgeon General’s Surgeon General’s ReportReport
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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
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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.
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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.
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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.
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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
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Raising Raising AwarenessAwareness
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METH MOUTHMETH MOUTH
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Thinking Out of The BoxThinking Out of The Box
“Never, ever think outside the box.”
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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
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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
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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
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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
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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)
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Special Thanks to Special Thanks to Jay D. Shulman DMD, MA, Jay D. Shulman DMD, MA,
MSPHMSPH
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““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