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Oral health of remand prisoners in HMP Brixton, London E. Heidari, C. Dickinson, R. Wilson and J. Fiske British Dental Journal 2007; 202: E5

Editor's summary

As well as providing an interesting overview of the oral health of remand prisoners, this study also gives a fascinating insight into the general health, habits and behaviours of this group of people. The demographic profile paints a picture of individuals who are disadvantaged in many respects and who in other studies or surveys may be categorised as non-regular attenders, without further definition. However, the additional information here is useful not only as a baseline for future planning of dental care within the prison service but also as a marker for practitioners who may see and treat such patients once they have been released.

Additionally the paper serves to illustrate the mixture we face in dentistry between the purely scientific, or clinical side of our work and the social or human aspects. If the paper had surveyed a 'population' of people with such poor oral and general health without specifying who and where they were, I wonder if our reaction would be the same as it is to knowing that they are prisoners? Of course, it should not affect the quality of care that we would provide but should their social situation and attitudes to health behaviour affect our treatment planning for them?

The use of alcohol and tobacco would place many of the studied individuals at greater risk of the development oral cancer, their diets and oral hygiene habits also suggest that the chances of retaining many teeth into older age would be substantially reduced. So how do we approach the treatment, or more pertinently prevention, of disease for such patients in order to increase their chances of rehabilitation into society and restoration of self respect and reasonable health? Although the authors state that there are few published studies on the oral health of prisoners, I suspect that we may well see greater attention to this section of society in the future.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 202 issue 2.

Stephen Hancocks OBE, Editor-in-Chief

Author questions and answers

Why did you undertake the research?

There are limited numbers of published studies related to the oral health of prisoners in the UK, but those that exist in both the UK and USA report that prisoners have poorer oral health than the general population. This matched the first author's subjective view based upon experiences at a young offenders' institute and a local male prison in London. Discussions with prisoners in the prison dental surgery led to an interest in the prison population's perspective of oral health. Prisoners appeared to justify continuous unhealthy 'behaviours' due to the high stress imposed on them in the prison establishment. We were interested in the attitudes towards oral health in relation to the normative need and wondered if there were differences between different prison populations, such as remand and convicted prisoners. This led to trying to understand more about prisoners' knowledge and views of oral health, past use of dental services, dental treatment experience, as well as their current oral health status.

What would you like to do next with your research?

We hope that the results will contribute to an understanding of the wider picture of factors that affect prisoners' oral health. In turn, we hope that this understanding can be used to improve the oral health care and dental service provision for prisoners, both locally and beyond. We would hope that the authorities (health or prison) could commission a larger study of prisoners' dental needs to look at the national versus local oral health need of prisoners. This would allow truly targeted commissioning of dental services, dependent on need.

There is also scope for investigation of other variables with a wider study, such as the skill base and mix required to treat this 'at risk' population. It seems apparent that this population has the need for dental care professionals with knowledge, training, experience and skills in special care dentistry. Also, what would be the role for dental care professionals such as hygienists, therapists and oral health promoters?

On the national level it would seem appropriate to develop a standard oral health needs assessment (possibly in collaboration with the Prison Health Research Network) to enable identification and comparison of needs within and between different type of prisoners and establishments. This could be linked to a study of 'discharge oral health status.' This would allow assessment of the effectiveness of prison oral health service during prison stay.

Further studies are needed to improve awareness of oral health status in different prison populations in the UK, at a national and local level. Studies should be linked to any local and national strategies for oral health service provision.

Comment

Remand prisoners comprise 18% of the total prison population in the UK, and only half of these go on to serve custodial sentences. This paper presents empirical evidence and methodological discussion of research on the oral health of this distinct subset, whose circumstances cannot be assumed to be the same as those of the general prison population.

The health behaviours of the sample are distinctive: 78% were smokers, 83% used illicit drugs, and they had both high normative and perceived needs for dental treatment. Fifty-four percent of the sample's most recent visit to the dentist was in prison and due to reduced barriers to access, the population use prison dental services more than on the 'outside'. Consequently longer stay convicted prisoners have better oral health than the remand prison population. Furthermore, HMP Brixton's whole team approach to health benefits convicted prisoners more than remand prisoners, again underlining the importance of considering this part of the prison population discretely.

In addition to the empirical contribution of this research, this paper also offers an engaging account of the methodological challenges in undertaking the work. Facing problematic recruitment for more conventional methods, the research utilises a convenience sample of 78 remand prisoners participating in structured interviews to address literacy problems written surveys would encounter. Participants were offered treatment in return for participation, raising issues of reciprocity as an ethical dimension of research.

The authors recommend that addressing the oral health of remand prisoners requires integrating dental screening into on-arrival medical checks, introducing oral health education programmes and integrating dental records into the new centralised electronic systems to help continuity of care. In a climate of stretched resources, it may be difficult to see this population as important, but clearly health care providers have a responsibility to marginalised groups with demonstrably compromised health, and with the remand prison population rising 6%1 between May 2005 and May 2006, this research identifies the issues relating to a growing service need.