Access to Oral Health Care in the Georgia Prison System
=======================================================

* Kandyce J. Mack
* Marie Collins

## Abstract

**Purpose:** The Eighth Amendment of the U.S. Constitution establishes the basis for inmates' rights to health care and includes both routine and emergency medical, dental and psychiatric treatment. According to Georgia's Correctional Standards of Health Care, inmates should receive a dental examination within 30 days of incarceration, instructions in oral hygiene and other care by a dentist when medically necessary. The July, August and September 2011 Georgia Department of Corrections' profiles of active inmates in the Georgia prison system reveal a need for both dental and dental hygiene services. The purpose of this article is to provide an overview of the access to oral health care of inmates in the Georgia prison system. Potential barriers to dental and dental hygiene services are identified and suggestions are offered to improve access to care for inmates.

*   standard of care
*   prisoners
*   health services cccessibility
*   oral health

## Introduction

The Eighth Amendment of the U.S. Constitution establishes the basis for inmates' rights to health care by prohibiting cruel and unusual punishment. The 1976 U.S. Supreme Court case, Estelle V. Gamble, 429 U.S. 97, further clarifies that inmates must be protected from “deliberate indifference to their serious medical needs.”1 The National Commission on Correctional Health Care (NCCHC) was established in the early 1970s to ensure the health care rights of inmates. This organization publishes its Standards for Health Services as a guide to health care delivery for correctional institutions and serves as a health care accrediting body for these facilities. Legally, inmates can expect to receive routine and emergency medical, dental and psychiatric health services.1

The Georgia Department of Corrections is the legal authority that oversees the state's prison facilities, which is described as the fifth largest prison system in the country, housing more than 60,000 inmates.2 The Office of Health Services of the Georgia Department of Corrections is responsible for the provision of health care to inmates housed in the Georgia prison system. Minimum standards of health care identified by the Office of Health Services include “the right to access to care, the right to care that is ordered, and the right to a professional medical judgment.”3 According to Georgia's Correctional Standards of Health Care, inmates should receive a dental examination within 30 days of incarceration, oral hygiene instruction, and care by a dentist when medically necessary.1 The purpose of this article is to provide an overview of the access to oral health care of inmates in the Georgia prison system. Potential barriers to dental and dental hygiene services are identified and suggestions are offered to improve access to care for inmates.

Dental care is listed as an essential health service by the National Commission on Correctional Health Care. As required by Georgia's Correctional Standards of Health Care, prisoners are examined to assess their dental health needs. The July, August and September 2011 reports from the Georgia Department of Corrections identify the dental health status of active inmates in the prison system upon intake into the facility (Table I).4-6

According to The Standard Operating Procedures, Department of Corrections, the dental examination performed at intake is done by a dentist and consists of dental history, teeth charting, and a hard and soft tissue evaluation. For each level of need, the subjective “D” or Dental Code index 1, 2, 3, 4 or 5 is assigned by a licensed dentist at the time of inmate intake. During the months of August 2011, September 2011 and October 2011, 49 to 50% of inmates presented with minimal routine dental health needs (D1), about 35% presented with moderate cavities and/or gum disease (D2) and 14 to 15% presented with extensive gum disease and/or widespread decay (D3). Less than 0.05% of inmates presented with an urgent need for dental services (D4), and even less presented with life-threatening disease, extreme pain or infection (D5). Dental treatment in the Georgia Department of Corrections requires a fee for service and/or copay.

View this table:
[Table I:](http://jdh.adha.org/content/87/5/271/T1)

Table I: 
Recent Dental Status of Active Georgia Inmates

The Standard Operating Procedures state that inmates with dental conditions that require immediate attention (D4 and D5) will be scheduled for treatment. However, non-emergency dental treatment (D1, D2 and D3) must be requested by the inmate. Emergency treatment in the Georgia Department of Corrections consists of extractions while non-emergency treatment consists of routine prophylaxis, scaling and root planning, closed flap curettage, amalgams, composites, temporary restorations, and removable prosthodontics.

In 1995, Thorburn proposed that one reason for the extensive dental needs of prisoners is that dentists are hired to perform both dental and dental hygiene services and often work without the aid of a dental assistant.7 In 2004, the Georgia Department of Corrections' 30 prison dental clinics employed full-time 8 dental hygienists and 22 dentists.8

The author communicated personally with the Dental Director for Georgia Department of Corrections, Dr. Cynthia S. Ditslear: Currently in Georgia, each of the 38 state prisons employs 1 dentist. This ratio of approximately one dentist to 1,600 inmates is well over the suggested 1:1,200 standard of care. Of the 38 state prisons, 29 employ 9 dental hygienists. There are 9 prisons which do not employ dental hygienists - the dentist is responsible for preventive and restorative services (Ditslear CS, personal communication, June 27, 2012). Dental expenditures steadily reduced from $3,871,600 in 2003 to $3,424,995 in 2004 to $1,475,072 in 2006.8,9 This reduction is reportedly due to a decrease in funding for oral health care.8

In an unpublished inquiry to dental directors of state prisons, Dr. Cynthia S. Ditslear found that Georgia is behind 3 of its surrounding states in meeting the standard of care for dentist to inmate ratio. The ratio of dentists to inmates is 1:1,200 in South Carolina, 1:1,026 in North Carolina and 1:1,200 to 1,250 in Florida.

In 2002, the president of the Medical College of Georgia appointed a group of various Georgia leaders in dentistry, education and government to the MCG Dental Task Force who later released a report that included 28 recommendations related to dental training programs, access to care and the shortage of dental faculty. In 2007, the president charged the dental school dean to revisit these recommendations and a new task force was formed called the Georgia Dental Task Force. A 2008 report from this effort recommended coordination between the state's only dental school and the Georgia Department of Corrections on Human Resources and Service Administration (HRSA) grants.10

The Task Force projected a graduating dental class of 100 students by the year 2016 and further recommended the use of Department of Corrections and Department of Juvenile Justice facilities as educational training sites for dental students.10 There are currently 16 accredited dental hygiene programs in Georgia. In 2011, these programs graduated approximately 215 students.11 Surveys are needed to determine staffing needs for dental hygienists, dental assistants and dentists in Georgia Department of Corrections facilities and how best to publicize these needs to graduating and practicing dental professionals.

## Conclusion

The Georgia Correctional Standards of Care emphasizes that access to health care is guaranteed by the U.S. Constitution. Dental care is a component of this health care right. One of the goals of Healthy People 2020 is to improve the oral health of U.S. citizens by increasing access to dental care. Georgia Department of Corrections' 2011 statistics provide the dental status for inmates as they are admitted to the prison. However, there are no formal monitoring mechanisms to track the current oral health status of inmates. Non-emergency and preventive dental treatment is not rendered unless inmates request and pay a fee for the services (C.S. Ditslear, personal communication, June 27, 2012).

With the disproportional increase of dental hygienists employed by the Georgia Department of Corrections compared to the number of prisons and increase in inmate population, training opportunities could be explored for dental hygiene as well as dental students. Current and proposed oral health care workforce models, such as the dental therapist, are excellent strategies to address dental needs for this growing and underserved population.12 Longitudinal assessments of the oral health care status of inmates are needed to determine the extent of a workforce shortage for this population. Having this data would aid the Georgia Department of Corrections in achieving its mission “to provide the required constitutional level of health care in the most efficient, cost effective and humane manner possible, while protecting the public health interests of the citizens of the State of Georgia.”3

## Acknowledgments

The authors would like to thank Cynthia Ditslear, DDS and Fayette McDonald, RDH.

## Footnotes

*   *Kandyce J. Mack, RDH, MS. Instructor in College of Allied Health Sciences, Department of Dental Hygiene, Georgia Regents University. Marie A. Collins, RDH, EdD, is dean of the School of Health Professions at Edison State College, Fort Myers, Florida.*

*   This study supports the NDHRA priority area, **Health Services Research:** Assess the impact of increasing access to dental hygiene services on the oral health outcomes of underserved populations.

*   Copyright © 2013 The American Dental Hygienists’ Association

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3.  Georgia Department of Corrections Health Services Mission Statement. The Required Constitutional Level of Health Care. Georgia Department of Corrections Office [Internet]. 2011 [cited 2012 February 26]. Available from: [http://www.dcor.state.ga.us/pdf/hsovrFY11.pdf](http://www.dcor.state.ga.us/pdf/hsovrFY11.pdf) 
    
    

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