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R. Gray, T. Fawcett British Dental Journal 2014; 216: E19

Editor's summary

In England and Wales about 150 people per 100,000 of the population are in prison. The number of prisoners had doubled in the last twenty years to about 85,000. In Scotland the rate per 100,000 people is similar – with the total prison population at about 8,100. In Northern Ireland, where this study was carried out, the rate is lower at about 98 per 100,000 (based on a prison population in 2012 of 1,774). Thus, the number of people incarcerated in the UK is not insignificant by any means.

Considering also that there is a high demand for dental care once a person is imprisoned and that there is a much higher prevalence of oral health problems in the prison population than the general population, prison dentistry is an important constituent of oral healthcare provision. Despite this, according to the authors of this paper, 'there is no standardised system for assessment and prioritisation of the oral health needs of prisoners in the UK and dental needs are not met during their admission time'.

Prisons are quite specific environments with which the vast majority of people are unfamiliar. It is very much a 'captive' audience of patients. There are lots of different protocols, systems and processes to consider when studying the prison environment. Even the jargon (terms such as 'landing staff', 'committal') is slightly different to the usual patient management terms we are used to seeing in this journal. But, even in this unusual environment, we find the familiar trend in which dental care is not necessarily well integrated into the general healthcare system. For example, in Hydebank Wood Prison and Young Offenders Centre, Belfast, analysed in this study, the authors found that when new prisoners are received the initial interview carried out by nurses did not cover any questions about oral health.

This paper discusses a trial of a triage system to prioritise patients' dental needs in the prison environment from this early interview stage. The aim was to reduce problems with waiting times and inequity in service by working collaboratively with prison staff to integrate oral health into the regular prison healthcare structure. Again, we see the familiar pattern in which integration of oral health into the general healthcare system (and the wider prison processes) reaps rewards. The authors found that the triage process was valuable – allowing patients to be seen in a timely manner according to their needs and introducing oral health advice into the regular prison healthcare structure. Though prison is a specific environment, there are certainly lessons in this study for all those involved in offering oral healthcare.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 216 issue 9.

Ruth Doherty

Managing Editor

Author questions and answers

1. Why did you undertake this research?

It is well documented that the oral health of prisoners is poor and that access to dental services whilst incarcerated is limited.

This study was undertaken to establish a triage pathway that would improve access to dental care. It was devised to enable prisoners at the time of incarceration to receive information about the dental service and at the same time give prisoners some oral and general health advice when starting their sentence.

By promoting collaborative working and interdisciplinary health promotion with prison and health care staff, it is hoped this research has helped promote a healthier prison environment.

2. What would you like to do next in this area to follow on from this work?

This study highlighted the need for patient centred oral health promotion and prevention whilst in prison. Improving the oral health of prisoners is a priority for dental services but resources and capacity are often limited. A study investigating the skill mix of a prison dental team used in oral health promotion and prevention is planned. Oral care clinics will be devised and delivered by a dental hygienist. Evaluation will be made of the oral health impact, service user views and the cost effectiveness of these clinics. This study could be useful in future commissioning of prison dental services.

Commentary

The challenges of providing effective dental care to prisoners are well recognised. They include trying to match the high level of treatment need with adequate clinical provision, which is often insufficient to meet the need and demand even before the designated treatment sessions are further shortened by unplanned security issues.

In order to move from offering a reactive service as has been common in the past, providing only urgent and emergency care to a proactive, planned service providing equitable care and offering health promotion, it is necessary to prioritise care by using some form of triage and assessment.

Whereas triage is widely used in general healthcare, as this study notes, dental triage systems in a prison setting that are commonly based on a self reporting screening process have struggled to separate urgent need from routine due to a 'reporting bias' whereby prisoners commonly and understandably exaggerate the severity of symptoms as this is seen as the only option to see the dentist.

This was clearly demonstrated in the prisoner's comments noted in a recent qualitative study carried out in Scotland as part of the development of a nationwide oral health promotion initiative in Scottish prisons:1

'You need to tell em you've got toothache, or you're in agony, and I think about 75% of the guys jus' tell lies cos they're just wantin' their teeth fixed you know.'

More experienced prisoners also noted differences between prison establishments:

'In this prison I've been to the dentist and in [second prison] and in [third prison]. In [the second prison] it was quite good and they were quite thorough – treated me well...'

Importantly, the perception that provision and quality of dental treatment across the prison estate is variable leads to a knock on effect that health promotion programmes can often be seen by both prisoners and prison staff as a low priority or worse, actively dismissed as an irrelevant panacea masking poor clinical provision.

This study reports the results of a multi-stranded approach introduced in Northern Ireland that includes a dental nurse led triage programme alongside regular assessment clinics and referral protocols for prison staff aimed at educating staff on how to recognise emergency and urgent need and thereby limiting non-urgent referrals.

Whereas the problem of reporting bias can never be eliminated, the development of an effective triage programme which could then be introduced across the prison service would hopefully lead to more fair and equitable access to dental care, which in turn should allow both staff and prisoners to be more open to engaging with health promotion programmes