Treating Chronic Oral Disease in a Correctional Setting
Providing inmates freedom from pain is no easy endeavor
Access to adequate dental care for millions of Americans continues to be an issue for which an all-inclusive solution is elusive, at best. As a general dentist who works within the correctional system, I see the consequences of this problem daily. My position as a full-time general dentist within the Hillsborough County Jail System in Tampa, Florida has clearly demonstrated how starkly the oral health and the general health of patients within the correctional system contrasts with patients I have treated in private practice.
The treatment of all dental patients begins with a complete review of their medical histories. The extent of chronic diseases in the patient population within the correctional setting is much higher than in a private practice setting. Infectious diseases such as hepatitis B, hepatitis C, and HIV/AIDS are common among inmates. Many of my patients are incarcerated for the use of illegal drugs or practices such as prostitution, robbery, or selling drugs to support their addictions to alcohol and/or drugs. These behavioral patterns are inconsistent with the ability to maintain steady employment and enjoy the benefits that typically come with it, such as medical or dental insurance.
A mindset of prevention is a foreign concept to most of these patients. Many of the patients I treat indicate that hospital emergency rooms are their sources of relief from pain, swelling, and infections of odontogenic origin. Patients receive analgesics and antibiotics to treat the immediate problem, but few have the financial resources to obtain definitive dental treatment that will provide long-term solutions for their dental problems. Because most of these patients lack the medical insurance that would cover their visits to the emergency room, the cost of their dental care and other hospital services is recovered at higher rates.
Similarly, the lack of medical insurance alienates these patients from adequate preventive and interceptive medical care, as most inmates receive their only medical and dental care during their incarceration. After release, most of these patients neglect chronic conditions such as hypertension and diabetes mellitus. Because the rate of recidivism is high among inmates, many return to the correctional system with a higher degree of morbidity from chronic diseases that have been left untreated during their release. Unfortunately, this is a repetitious cycle, as the funding from private sources and government sources for free or low-cost medical clinics is becoming increasingly scarce.
The ways in which dental treatment within correctional institutions is rendered varies. In our setting, we are essentially an emergency dental clinic, providing extractions of teeth that are grossly carious, non-restorable, or periodontally hopeless. At the state and federal levels, restorative, periodontal, and basic prosthetic treatments are provided. Small facilities usually contract with local dentists to provide emergency dental services. Because all correctional systems depend on tax revenues, budgets for medical and dental staffs and supplies are under strict guidelines and scrutinized by the administration and management of these facilities. Some facilities charge copays for medical and dental treatments, but as many within the inmate population are indigent, only a small amount of the cost of medical and dental care is recovered.
Unlike a traditional private practice, security is the top priority within any correctional setting. We are required to count all instruments, needles, scalpel blades, and sutures at the beginning and conclusion of each shift. Inmates can never be left alone in any clinical setting, as basic supplies such as tongue depressors or pens can be used as weapons. In our facility, dental floss is contraband, as it can be collected, banded together, and fashioned as a weapon to be used to strangle someone or used as a means to commit suicide. Salt is also prohibited as it can be collected and thrown into the eye of another inmate.
Such rules vary among correctional institutions. Security training is part of the orientation of every healthcare employee and with it the practice of not letting your guard down during any patient encounter. While this protocol is absolutely necessary within the correctional setting, it is not conducive to an ideal relationship between the provider and patient.
Most of our patients are grateful for the services we render, as providing relief from pain of odontogenic origin is a noble undertaking, whether it is in private practice or a correctional setting. I treat each patient with a sense of the respect and dignity that should be accorded to any human being. The inmate’s perception of the entire dental profession may be based on the encounter with my assistant and me, so we strive to provide a level of service that will make a favorable impression and motivate the inmate to seek dental care after release.
Mark J. Szarejko, DDS, FAGD
Hillsborough County Jail System