Prisons Failing in Dental Care for Inmates, say Researchers

Dental health of inmates is among the least studied areas of correction health. But clinicians warn that inattention to this area of medical care affects morale and behavior behind bars—and can be life-threatening.

As health care services and costs continue to drive the public discourse, dental clinicians inside prisons and jails and correctional health researchers are highlighting what they contend is a dire need to integrate oral health care into overall medical planning for inmates.

Generally, inmates enter the criminal justice system with higher rates of disease than that affecting the broad public. That includes higher rates of often unattended chronic illnesses that some research has concluded is directly linked to poor oral health.

In extremely rare cases, oral infections have proved deadly.

Arguing for better and more standardized dental care for the incarcerated, two researchers wrote last year in an American Journal of Public Health editorial that including data on inmates’ dental health in the National Health and Nutrition Examination Survey would be a good starting place for improving dental services in corrections.

The survey broadly captures health information on non-incarcerated people and is a key tool in healthcare planning and forecasting.

The editorial’s co-authors, both dentists, are a Texas A&M dentistry professor who also has been an expert witness in lawsuits about prison dental services and a U.S. Public Health Service assistant surgeon general.

They contend that inmate dental health—despite major lawsuits by incarcerated persons alleging that their serious dental problems weren’t tended to—is too far outside the spotlight of urgent needs in correctional health care.

“For the most part, prison systems are not worried about inadequate dental care,” said Dr. Jay Shulman of Texas A&M. “Prisons are typically not going to do any more than they have to in order to comply with Eighth Amendment, which means the care doesn’t have to be good.

“It just has to not be so bad as to constitute deliberate indifference and infliction of pain. That’s the correctional standard.”

He continued: “Estelle v. Gamble, the seminal case out of Texas, says that prison health care violates the constitution only when it’s so bad that it is … reckless, deliberate indifference to a serious medical need.

“That’s a very high bar. Prison systems know they won’t get sued very much because it’s hard for inmates to sue for malpractice or deliberate indifference. Generally, they just don’t have the resources.”

The editorial urges:

  • Correctional facilities to create electronic health systems similar to ones that are yielding more coordinated care among the non-incarcerated.
  • Nationwide networking among correctional health executives who might confer on how to create a better system out of what now is a patchwork of services that vary widely, locale by locale.
  • Training in college undergraduate and graduate dental programs to widen the potential pool of dentists, dental hygienists and dental assistants working in corrections.

Dr. Morton Rosenberg, a clinician who serves as the California’s Department of Corrections and Rehabilitation dental director, has been an expert witness in federal class actions demanding better dental care, drafted correctional dental care policies and monitored such care in states where the courts demanded improvements to dental services for inmates.

California’s own revamped dental care program—some hail it as a model for better oral medicine for inmates—resulted from 2005’s  Perez versus Cate/Tilton class action. A federal court, siding with the plaintiffs, affirmed that the state had violated its prison inmates’ right to dental care, which the U.S. Supreme Court guaranteed in 1976.

Rosenberg said the Perez decision, since it was settled in 2012, has yielded what today is not only more sufficient dental care but also a coordination of dental, medical and mental health services that he lauds as cutting edge and suspects is comparatively rare.

“We went from no policy and procedures to a system that was very structured and subject to federal court monitoring,” Rosenberg said.

“Over a period of few years,” he added, “we developed a very robust program. That has happened with a lot of help, working with our medical and mental health colleagues as we [handle] patients with co-morbidities. Not just dental and medical needs, but sometimes mental health needs.

“Also, we work with [correctional] custodians so that we can do dental work that doesn’t collide with chow or count time. Working collaboratively, we’re able to be very successful.”

California gives inmates what it deems as basic dental services, treating, say, tooth decay and supplying dentures but not dental implants or other cosmetic care.

“We want to stabilize any conditions that will affect their ability to participate in daily activities, being able to sleep and eat, do whatever they would do in a prison classroom or a rehabilitative program such as in a cabinetry shop,” Rosenberg said.

“Pain will obviously distract them and make them not want to do what they should be doing. Severe dental pain can make some pretty tough-nutted people … not even want to get out of bed.

“And a tooth infection that becomes septic, having been left untreated can be life-threatening.”

His patients have ranged from those who’ve been shot in the face, losing teeth and jaw and facial structure to methamphetamine addicts,” he said. “And its affects have destroyed their mouths.”

Dental health of inmates is among the least researched areas of correction health.

The editorial by dentist Shulman and co-author Dr. Nicholas Makrides, who had been the chief dental officer at three federal prisons, is part of their ongoing bid to ramp up the scientific focus on inmates’ dental health. In 2002, they co-authored a study concluding, among other findings, that “there was substantial variation in the way dental care was provided to inmate populations by the states.”

At that time, according to that study, published in the Journal of Correctional Health, 52 percent of 45 states responding to the researchers’ query required inmates to make a co-payment for dental services. Seventy-three percent of those responding states had dental directors for their prisons; and 72 percent described their prisons as providing emergency care and some routine care.

Additionally, the study found no correlation between how wealthy, or not, a state was and the level of dental care it gave inmates.

Katti Gray is a contributing editor of The Crime Report. She welcomes comments from readers.