Providing dental care in prisons

Care provision

The UK Department of Health (DoH) became responsible for healthcare in prisons in 2003, taking over from the Home Office. Dental Care in prisons is commissioned from the DoH specification,² introduced on takeover in 2003, and is provided free of dental charges. There are two groups of prisoners; those who have been convicted of criminal offences and are serving a custodial term – a ‘prison sentence’, and those who are ‘on remand’ awaiting a court hearing. At the time of the 2003 specification, the suggested commissioning was for one dental session per week for every 250 prisoners. This is still being applied to the current date. Dental care is provided from dental surgeries within the prison itself, although often the only reminder that this is a different environment is the presence of bars on the windows as the surgery will be identical to those seen in high street environments (Figure 1).

In the 2003 specification, which still stands, convicted prisoners are provided with full courses of treatment as Mandatory Services from the General Dental Services of the NHS.³ Remand prisoners are usually considered still to have their own dentist until actually convicted, so their care outlined in the strategy is ‘Occasional Care’ – in effect urgent care only for specific problems. This reflects the fact that they have not faced a conviction. They are (theoretically) still under the care of their own dentist. Although this 2003 specification still stands, there have been a number of interpretations on how this is applied in the prison environment,^{4, 5, 6} with an emphasis on providing permanent restorations (if possible), though without any advice on how to manage demand or relate this to the 2003 specifications. Treatment for both groups is provided free of charge. The General Dental Services have updated ‘Occasional Care’ with ‘Urgent Treatment’,⁷ which is difficult to translate to the Prison Environment and the Remand Status.

Special features of the prison environment

The main function of prison and detention centres is to detain inmates and to support them to prevent re-offending. Secure hospitals, in addition to providing detention, have the primary function of treating severe psychiatric disease. The inmates spend much of their time within a cell with very basic facilities (Figure 2). This may be locked for many hours a day (Figure 3). Access to oral health aids varies from prison to prison but will often be limited to just toothbrushes and toothpaste.

Prisons are graded into four categories in relation to the types of prisoner they hold,⁸ reflecting their level of security (Table 1). Female prisons have four grades that are very similar.

Prisoner induction includes a health assessment and outlining of the Prison Rules.⁹ This legislation outlines how prisons are run and that prisons have a ‘no touch’ policy towards staff, which is explained to prisoners at their induction. Prison Rule 51 specifically describes the relationship between staff and prisoners. Generally, dental staff working in prisons see them as relatively safe environments.¹⁰

Challenges in providing prison dental services

In 2005,¹¹ two challenges were seen for implementing the 2003 modernization strategy in preparation for local commissioning by Primary Care Trusts in 2006 of health services in prisons. These challenges still remain:

The factors that make it more difficult to provide dental services to prisoners than to the general population are summarized in Figure 4 as conflicts between Demand, Needs, Supply (capacity) and Resources.

There is tension between high levels of dental need, especially urgent care, and demand for services. Access to care varies with institution, with prisoner movements to the dental surgery being more difficult the higher the security level. Levels of non-attendance are high; prisoners often place paid work, visits, gym and education sessions above dental attendance. Security affects access, as lockdowns and security checks prevent prisoner movements. Escort Officers can be in short supply as other security needs arise around a prison.

The prison population is not a stable patient base; prisoners are moved around for a number of reasons including changes in their status and for disciplinary reasons. Short sentences and location changes result in courses of treatment that are often not completed.¹² This can also make care provision difficult; in England and Wales commissioning still tends to be on the basis of set population figures of one commissioned dentist day per 250 prisoners, but over the course of a year a prison's turnover can be several thousand due to remand prisoners, licence recalls, short sentences and inter prison movements.

Full dental records do not follow prisoners, so they may require repeat assessment following each transfer, and there is a problem with continuity of care for complex interventions, especially when a referral to secondary care has been made. Dentists in every prison record dental records in a variety of ways that include cards (such FP25 NHS dental envelopes), stand-alone systems and also brief entries on medical health systems, such as SystmOne®. Without standardization, it is difficult for records to follow the prisoner.

Complaints and litigation

Patient complaints in prison are a growing problem. Prisoners are more likely to complain if they feel that they have not been provided with the services to which they perceive they are entitled. They are less likely to understand their role in care. Effective management skills in understanding and learning from complaints are essential.

It is not uncommon for requests for care to be made soon after entering the prison system, when very little attempt has been made before. Prisoners look to sorting out their dental problems while in custody. With no other distractions and a lot of time for self-reflection, there are often unreasonable expectations in terms of what can be achieved and regarding access to the care available. After often years of inattention, poor dental health has to be managed within the practicalities of a prison environment with treatment that is practical and achievable.

Institutional living brings with it a sense of being provided for, making it difficult for patients to understand the need to take personal responsibility for their oral health. In addition, every prisoner comes with a lawyer attached. There are some aggressive litigation firms looking to profit from prison healthcare by finding any loophole or event where the outcome is not ideal, opening debates about the morality of making money from crime.

Oral health

The 2003 commissioning specification acknowledges that people in all types of detention have health likely to be worse than that of the population as a whole, made worse by the general environment of close communal living. Specific factors known to have affected dental health include a high prevalence of smoking (in 2017 UK prisons underwent a smoking ban), substance abuse with damaging contaminants¹³ and associated dietary problems, poor mental health, learning difficulties and low socio-economic status.^{14, 15} Physical health may be poor, due to lifestyle issues such as living on the streets to ‘being on the run’ attempting to avoid the justice system. Prisoner health is likely to be worse than that of the population as a whole, affected by close communal living.¹⁶ Substance abuse is associated with high levels of caries; from the ‘sugar rush’ addicts crave for high calorie foods and from the disguising of pain from opiates, etc, that would normally signal a need to access dental care. This means that devastating and rampant caries is often observed when abusers eventually present for care in the prison environment.¹⁷ Treatment for addiction also brings risks, eg use of methadone syrup which is also associated with caries. Substance abuse is also associated with high levels of blood borne diseases, including HIV and Hepatitis in all its forms. Chaotic lifestyles and low personal esteem associated with substance abuse relegate dental care to a low priority.

Oral health of those entering prison is poorer than in the general population.^{11, 18, 19} As addiction problems in custody are addressed, the pain-masking effects of many street substances are lost and the full extent of personal dental neglect becomes clear. Dental pain quickly becomes more noticeable and more of a priority. Local anaesthesia can be more difficult to achieve as street substances, such as opioids and cocaine concoctions, can negatively modify the effectiveness of common preparations. For example, it is not uncommon for many cocaine derivatives to be mixed with Benzocaine as a bulking agent to make them go further.

Deprivation and social exclusion found in inner city areas is reflected in a high proportion of prisoners coming from these areas, where employment can be around 50%. Oral diseases, like many other diseases, are linked to high levels of social exclusion. Chaotic lifestyles lead to oral neglect and poor nutrition. Untreated dental disease within the prison population is approximately four times that found in the equivalent socio-economic groups of the general society.²⁰ The prison population, in addition to having increased dental need and poorer dental health, also tends to be less likely to access care.²¹

Age of population

With increasing rates of conviction for historical offences, the prison population is including older adults with specific and increasing dental needs. Christensen noted that the older population group is becoming increasingly dentate²² and there are factors that make them more susceptible to dental disease. The most common oral problems in older patients were identified by Christensen as:

Untreated caries is generally higher in the household resident elderly population than in the general adult population and older adults living in residential environments, including custodial environments, have higher caries prevalence and report more pain than in the general adult population. They are less likely to have a functional dentition.^{23, 24}

In the older population, oral and dental degeneration is related to years of chewing, smoking, trauma and dysfunctional oral habits, along with heavily restored dentitions requiring a high degree of maintenance. Destructive effects of periodontal disease are more likely to be seen in older age groups because of the chronic nature of the disease, although ageing has no direct damaging effect on the periodontal tissues.²⁵

The Oral Health Foundation Charity²⁶ warns of dental problems in those aged over 50 who have dentures, partial dentures and bridges, which can also become the cause of other oral health problems, such as dental stomatitis (thrush). When linked to socio-economic and lifestyle factors these problems become compounded.

Mental health

Detained people are likely to have worse health than that of the population, because of the general environment of close communal living.¹⁶ It is recognized that there is a higher incidence of learning difficulties and mental health problems in the prison population.²⁷ Recent figures show that 39% of offenders supervised by probation services, and up to 90% of prisoners, have some form of mental health problem.²⁸ Cognitive difficulties due to dementia, an acquired brain injury or a learning disability make the provision of care more challenging. Severe mental illnesses may be behind offending behaviour and such offenders from a prison, YOI or IRC, are sent to be treated in mental health hospital services using Section 47/48 of the Mental Health Act.²⁹

Due to low levels of literacy and incomplete education, prisoners may lack mental capacity for a specific decision at the time it needs to be made for a wide range of reasons. Before intervention begins, physical health, mental health, neuro-disability and substance misuse needs are assessed and may require ‘Best Interests’ decisions to be made under Section 4 of the Mental Capacity Act 2005.³⁰

Staff competencies

Specific skills are needed for working in the prison environment. Four domains are described by the Faculty of General Dental Practitioners (UK) for dentists in prison dentistry,³¹ building on the areas of the COPDEND domains framework for Foundation Training³²and those outlined by the UK General Dental Council for registration.³³Table 2 outlines the skill sets required to work in a prison environment and recognize the enhancements needed for the special environment.

Conclusion

The prison population receives dental care that is provided under specific security requirements of the prison system. This requires very specific skills sets from the dental team in addition to their dental skills. Development of good communication and behaviour management skills is important, as resources such as conscious sedation may not be available and the prison population tends to have unreasonable expectations about treatment outcomes. Because of a number of social and lifestyle factors in the prison population, there are more dental problems that present significant challenges from poorer oral and general health than are found in the general population.