Sir, I read with much interest your editorial Dentists behind bars (BDJ 2010; 208: 145). I am a Dentist with Special Interest in Prison Dentistry and attended the 3rd annual NAPD(UK) conference you mention.

Having been a prison dentist for some six years, I am pleased that the NAPD(UK) has brought this small proportion of the profession together and raised its profile. Recent recommendations regarding the reform of prison dental services1,2 have been positive but the number of clinicians obtaining DwSI in PD remains low. Prisoners have significant dental health needs, have had little previous dental intervention and have a high proportion of mental and physical problems.3,4 Ninety percent of prisoners have a mental health problem, a substance misuse problem or both. The demand for emergency care is high as inmates undergoing drug detox discover previously masked dental pain. Substance misusers also have a lowered pain threshold and are commonly dentally anxious. Lifestyle habits contribute to poor dental health as well as the substance misuse.5 A high proportion of inmates have language and/or communication difficulties.6

It is unfortunate that the time when the role of the prison dentist has formal competencies in the form of DwSI contracts2 has coincided with the current financial situation. I have recently had my clinical time reduced by a third and each year 3% of the prison dental budget is reduced. Under these circumstances, it is very challenging to offer a full service, as emergency patients are always prioritised. Such reductions may prove a false economy as the need for dentistry will not reduce and prisoners taken to outside hospital when the prison dentist is not available are escorted by prison officers, the cost of whose time is re-charged to the PCT. It will not need many outside transfers before the cost of the reduced sessions is exceeded.

Each PCT is now responsible for commissioning services within prisons falling within their geographical area. With some PCTs having only one prison in their area, there are many commissioners who are faced with difficult financial decisions over a wide range of healthcare services with which they may not have direct experience or knowledge. There is a risk that all commissioners are required to independently familiarise themselves with prison dental services and current recommendations.

At the conference of NAPD(UK) it was obvious that there were many experienced and skilled prison dentists in attendance. It was, however, generally reported that some commissioners were reluctant to recognise demonstrated competencies by considering a DwSI contract, even when this is cost neutral. It is clear that if this field of dentistry is to provide the best standard of care with skilled clinicians, further attention by understanding commissioners is essential.