Dental nursing behind bars

BDJ Team is pleased to publish this glimpse into the daily life of Community Dental Services prison dental nurse Cassandra.

Community Dental Services (CDS-CIC) is an employee-owned social enterprise providing community dental services and oral health improvement programmes. CDS is also contracted to provide dental services in prisons. These prison dental contracts are part of the wider prison healthcare system, and the healthcare team includes doctors, nurses, podiatrists, opticians as well as the dental team.

Here we are given an exclusive insight into prison dentistry through the eyes of a CDS prison dental nurse.

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I started my career as a prison dental nurse in October 2020. I was attracted to the role as my passion is to help people and improve oral health. It is really important that people understand how much impact their oral health will have on their overall wellbeing. I felt that the prison setting would be somewhere I could make a real impact.

In prisons we see an elevated level of dental neglect: this can be down to historical substance misuse, along with a general lack of understanding of how important dental health is and no continuity of dental care. This all results in the dental team having more demand for its services than any other health service within the prison setting. As access to dental care is available in the prison setting, it is often the case that people have not been able to see a dentist for some time before they end up in our system.

I enjoy my job as no day is the same. I have full responsibility for my surgery, and I constantly get to meet new people. I am supported by my line manager and CDS which is important - a prison setting is very different and can be quite disorientating until you are used to it. Being the only dental nurse on site can be very demanding, but I know that the whole team are behind me and are only a phone call away if I need them. The support from them and my line manager has been fantastic. We try to maintain visibility within the prison setting, making sure we are sharing oral health information and that people know how to request an appointment if they need one. It is especially important to engage with new prisoners on arrival and we give out welcome packs with information on oral health and how to make an appointment if they need one. We also have information in 'easy read' format and in other languages to assist with communication barriers.

A typical working day for me starts as I enter the prison site. I go to the gate lodge, where I must show my ID badge. Then I go through the security doors by scanning my fingerprint. I then have to get my keys from a cabinet that also is by fingerprint access and attach them to my key chain and belt. I have access to a radio that is on the prison network. A bag search and body pat down are done and sometimes, I get sniffed by the drug dogs.

Before I reach my surgery, I must go through nine locked gates and doors! When I get to our healthcare department I speak to our detailed officer (this is the officer who has been assigned the daily role of supporting the healthcare team with their duties) to let them know the dental team is ready to start seeing patients.

Patients book their appointments via an application form. This is either a paper form or in some prisons where access to a laptop is available, it can be done electronically. The patient will state on their form why they need to see a dentist and the application forms are then submitted to the dental team. As the dental nurse, I play an important role in triaging requests for care to assess the urgency and then schedule an appointment for them. The officer on duty has a list of patients who have an appointment, and the patients also know a day before that they have an appointment.

I set my surgery up, which is quite similar to the normal setting up of a dental surgery but in a prison setting. We must unlock every cabinet because they have to remain locked when not in use. I then make a start on the application forms whilst I wait for the dentist to arrive.

It is the role of the dental nurse to create our triage waiting list. Each nurse has a designated triage day to see the patients face-to-face, to find out what sort of appointment they need, discuss options, and go through oral health advice with them. We carry out face-to-face or telephone triage appointments on our own, but if we need to go to a cell or if the patient is a risk, then we have an officer present for security. Dental nurses are working alone most of the week. Despite having lots of work to keep us busy, you need to be able to work on your own and not mind this.

All this happens before the patient gets to see the dentist, and despite the triage process, we do sometimes get people booking appointments who do not actually need them. When it comes to patients attending their appointments it can be hit and miss for several reasons: perhaps they choose not to attend; maybe they fail to attend as they are on yard time, which is when they get their exercise; or because of issues happening more widely in the prison.

When the patients arrive at Healthcare, they are locked in a waiting room by the on-duty officer and then checked in by a member of the Healthcare team. The Healthcare teams are employed by the healthcare provider and consist of doctors, nurses, podiatrists, opticians etc. There is one waiting room for all healthcare appointments. When we are ready to see the patient, I collect them from the waiting room and escort them to the dental surgery. The officer stays in the healthcare office as they are responsible for the whole of the healthcare provision - they do not come into the surgery with us unless we specifically call for them.

If there was an incident which meant we were in danger, we have a panic button in the surgery. The alarm is pressed somewhere within the prison on a daily basis. When the panic alarm is pressed, the officers closest to the alarm's location will run to the incident and deescalate the incident or restrain the prisoner(s) causing concern. I have not needed to press the alarm, but the first time I saw an alarm response, I found it extremely daunting and was quite scared, but now it is part of my day-to-day work and I think it would be strange not to hear an alarm during my working day!

Seeing and knowing that an offender can finally smile and have an improved chance to seek employment gives me immense pride and job satisfaction.

Another difference to dental nursing within a prison is around our instruments. Every metal instrument has been individually etched with a unique number, so if it goes missing, we can work out what it is and who may have taken it. We must always count our instruments and we have a sheet that records all the instruments that are used on the patient, as well as counting them in and out. We send this daily log to security. I have never experienced a missing instrument, but if that were the case, our log would show all the instruments used and patients seen. The security teams would identify those in attendance during the time the instrument went missing, and they would be locked up whilst cell searches were conducted. If patients had returned to the waiting room after we saw them, ALL patients would be searched as the instrument may have been passed on to someone else.

There is only one dental nurse at each surgery who is responsible for the dental clinic. Our role is fantastically varied, and our duties include:

• Booking and managing the diary (ie receptionist duties)

• Decontamination: this must be done on site

• Audits: these include security audits for the prison, our own internal CDS audits; infection control CG audits; medication audits for pharmacy

• Escorting patients and nurse triage

• Stock ordering of all dental stock required for the surgery. We also have to order directly from the prison for the department ie toilet rolls, cleaning equipment

• Security checks: tool counts and confirming with security all dental equipment is counted in correctly

• Record keeping: as we do not have a receptionist in the prison service, our role requires us to scan in all patients' documents, medical histories, consent forms etc

• Attending monthly resident council meetings. We meet with appointed council members consisting of a resident representative from each wing in the prison (anything from six to 11), where we address concerns raised by other residents. Attending also allows us to share updates about the department.

I strongly believe that CDS providing prison services is important as we actively promote oral health. From my experience, historically prisoners believe that a prison dentist is just there to extract teeth and send you away. CDS is passionate about patient care and oral health, and I can really make a difference. During appointments I always explain that CDS is all about prevention and oral health education. My triage clinics give me time to talk to patients one on one, through which I have discovered the larger percentage of offenders have had no oral health education and their oral health is extremely poor. I am incredibly grateful that my role gives me time to provide this education. Many of the offenders are edentulous or have very few sound teeth left and have no idea that dentures can be made for them. Seeing and knowing that an offender can finally smile and have an improved chance to seek employment gives me immense pride and job satisfaction.

There are many challenges in the prison environment, and we are still dealing with the legacy of COVID-19 which has meant long waiting lists for treatment. It's an environment I find really rewarding though and I can definitely see I'm making a difference.

If you are interested in working with the Community Dental Services visit https://www.communitydentalservices.co.uk/work-for-us/current-vacancies/.

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