Th Rdh118056 82

How they "manage" behind prison walls

June 1, 1997
Dental hygiene in correctional institutions is an unique and challenging career. An explosion of the inmate population in Texas sets the stage for another institution - managed care.

Dental hygiene in correctional institutions is an unique and challenging career. An explosion of the inmate population in Texas sets the stage for another institution - managed care.

Pamela J. Myers, RDH, CCHP

Being a full-time practicing dental hygienist for the past 24 years has afforded me many opportunities, but none have been as interesting or as challenging as my present position.

The majority of dental hygienists practicing in America are in a private-practice setting. Many other opportunities for dental hygienists seldom are explored in depth. My practice is one of those "other opportunities."

I practice in a medical infirmary located inside a state prison. I am the dental-hygiene coordinator for the University of Texas Medical Branch - Correctional Managed Health Care (UTMB-CMHC). We provide care to the offenders incarcerated in the Texas Department of Criminal Justice (TDCJ). With a total inmate population of more than 146,000, the TDCJ is the second largest prison system in the United States.

Ninety-three percent of the inmates are males. They range in age from 13 to 80, and the average age is 34. They are from different ethnic, racial, and economic backgrounds. The average educational level of these patients is 7th grade and their average IQ is 91.

The standard of care available to these patients is equal to the community standard for basic dental care.


Within the last 10 years, the Texas penal system has undergone dramatic changes and rapid growth. As a result of state legislative action during the 1990 session, the Texas Department of Corrections (TDC) became the Texas Department of Criminal Justice (TDCJ). TDCJ then became an umbrella agency with three distinct divisions. The TDC became the Institutional Division, which manages prison detention and treatment facilities. The remaining two divisions are the Parole Division and the Community Justice Assistance Division, formally probation.

In 1992, the State Jail Division was added to the umbrella agency by the state legislature. This division was created to house offenders from county jails who would be eligible for parole in two years or will enter the Institutional Division within 12-18 months. The State Jail Division was established to alleviate overcrowding in the county jails.

Until 1994, dental-staff members providing care to inmates were employed directly by the TDCJ. During the 1994 legislative session, a unique partnership to provide health care to inmates was created. A Managed Health Care Advisory Committee was established to oversee the health care provided to inmates through a cooperative effort involving the TDCJ, University of Texas Medical Branch, and Texas Tech Medical University.

The factors prompting the legislative action were:

(1) An unprecedented expansion of the criminal justice systems

(2) Shrinking state budget resources

(3) Rising health-care costs

(4) Increasing incidence of HIV/AIDS and TB

(5) Difficulties in recruitment and retention of health-care professionals

(6) Prison litigation

- Shrinking patient base at university medical schools

- Endangered rural hospitals

In 1991, M. Wayne Huggins, director of the National Institute of Corrections, described the health-care issue this way: "Few areas, aside from overcrowding, cause correctional administrators more concern than providing health services for inmates. A perennial problem is how to deliver quality health services to inmates on a timely basis in a cost-effective manner."

As a part of the Texas Performance Review, the following recommendations were made concerning health care in the TDCJ.

(1) A managed-care system should be established for TDCJ inmates.

(2) A managed-care system would control increasing prison costs.

(3) Current and future cost reduction should be achieved through implementation of such a program.

"The prison environment lends itself to a managed-health- care system because there is a defined population of prisoners who must receive health services," the Texas state auditor`s report stated.

Correctional managed health care

The correctional Managed Health Care Advisory Committee was charged with establishing a statewide health-care network, maximizing use of state medical schools, and using managed-care tools to contain costs.

All TDCJ facilities are accredited by the National Commission on Correctional Health Care (NCCHC). NCCHC standards classify dental care as an essential need and mandates that dental education and oral-hygiene instruction be provided to all inmates. Basic dental education is essential for successful treatment of TDCJ patients because the majority of them are dentally illiterate..

Large and small group counseling, as well as individual chairside instruction, are our three main methods of education. Inmates are much better students than you would imagine. It is professionally challenging to communicate dental information and demonstrate oral-hygiene techniques to patients whose dental experiences in the past were limited to the "alleviation of pain."

Some special programs have been developed and implemented in the last 10 years in response to the needs of our growing prison population. For example, young first-time offenders, ranging in age from 17 to 25, are assigned to "boot camps." They are in a regimented program, which includes classroom time devoted to life skills. Dental hygienists provide two programs to them - "Oral Hygiene & Oral Health," which includes information about being a wise dental consumer, and "Tobacco & Oral Health."

The Tobacco & Oral Health program is provided to pre-release groups and prenatal groups. Tobacco is abused regularly by 90 percent of all offenders prior to incarceration. Until 1995, tobacco was allowed and actually provided to inmates. As a result of legislation, the TDCJ became a tobacco-free environment. Inmates are not allowed to possess or use tobacco products. As a result, the TDCJ already has exceeded one of the Healthy People 2000 objectives, which is a national health-care initiative.

In addition, we provide prenatal dental-health education. At any given time, we house approximately 100 pregnant women. The prenatal dental-education program includes information about bottle caries, pregnancy gingivitis, nutrition, and dental health.

The largest ongoing community dental-health program we provide deals with periodontal disease. This program was developed and implemented in 1988 and has proven to be very successful. All dental professionals realize the importance of optimal oral hygiene in the control of periodontal disease. In our program - the first of its kind in any penal institution in this country - the patient`s role is stressed throughout treatment. This program has had a positive impact on the inmate population by instilling the concept of personal responsibility for dental health.

The initial phase of this program involves identification and typing of periodontal disease, which is followed by plaque-control counseling. This counseling includes information regarding etiology, progression, and prevention of periodontal disease. Instruction in proper oral-hygiene techniques, using a soft-bristled toothbrush and a dental-flossing device, also is provided. Other phases of this program address nonsurgical periodontal therapy and periodontal-health maintenance.

Patient cooperation is essential throughout the treatment plan. Documented, acceptable oral hygiene is required for patients to remain in the program.

Our changing prison population has required the development of programs for our hospice and total-care patients.

Dental care

Dental services are provided according to an established priority system. Priority of care is determined by the treating dentist based upon a dental examination. The priorities of care are: Priority 1-emergency, Priority 2-urgent, Priority 3-interceptive, Priority 4-rehabilitative, and Priority 5-complete.

Diagnostic, preventive, clinical hygiene, nonsurgical periodontal therapy, restorative, extractions/oral surgery, limited endodontics, and removable prosthodontics are services that are available to inmates.

An acceptable plaque index is necessary to be eligible for Priority 3 or 4 care. A plaque index is used as an education tool and to gauge an inmate`s oral-hygiene improvement. The plaque index is derived from the following formula:

The number of teeth exhibiting plaque X 100 = %

The number of teeth present

Acceptable oral hygiene is a plaque index score of 20 percent or less, or an 80 percent plaque-free oral environment. An average inmate can attain acceptable oral hygiene in 2.27 appointments according to results from a recent study.

An evaluation of the nonsurgical periodontal program was performed using data collected from 37 inmates. These patients had been diagnosed with types III and IV periodontal disease. The inmates were followed for up to 48 months with the average length of treatment being 18.5 months. The average decrease in pocket depth for these patients was 1.23 mm.

My patients do not pick up a telephone and call for an appointment. They must place a written sick-call request asking for dental care to be scheduled. The TDCJ is required to collect a $3 copayment from each inmate who requests or initiates a visit to a health-care provider. This $3 charge will be deducted from the inmate`s trust-fund account. Under no circumstances is access to health care denied due to failure or inability to make a copayment.

Once an inmate requests care, the copay applies for the visit, unless it is a true emergency. When the dental treatment plan is formulated, there is a $3 copay. No other copay charges apply until the treatment plan has been completed. After treatment, patients are advised as to when they are eligible for the next prophylaxis. It is their responsibility to request care at that time. Amazingly, inmates do not forget their eligibility dates.


In 1997, UTMB-CMHC began working on affiliations with dental hygiene schools in areas where TDCJ facilities are located. With an affiliation agreement, UTMB and TDCJ are able to bring the schools` dental hygiene students in to work in the prison dental clinics. UTMB-CMHC dentists supervise the hygiene students.

This arrangement is beneficial to all parties. The students have a greater patient base needed to meet their clinical requirements. The dental-hygiene schools have a clinical alternative that qualifies for a community-based program.

UTMB/TDCJ benefits by having additional providers. The patients benefit by receiving quality care. The student`s enthusiasm is contagious and positively impacts our overall program. At present, UTMB/TDCJ has affiliations with three dental-hygiene schools and one dental-assisting program.

When addressing groups of dental hygienists or hygiene students, I often am asked questions related to safety, patient treatment, and environment. The general misconceptions about penal institutions stem from the media. TDCJ facilities are not dark, dirty "dungeons." Our dental clinics are equipped with modern equipment and adequate supplies to provide care. When entering any prison facility you see manicured lawns and beautiful flower beds. The floors in the prisons are shined to almost mirror images.

Am I afraid to work behind bars? No. I act as a health-care professional and I`m treated like one.

What about infection control? Personal protective equipment is provided to all staff members and written policy requires its use. We regard all of our patients as potential carriers of infectious disease and utilize universal precautions at all times.

UTMB and TDCJ perform regularly scheduled audits of our health-care operations. UTMB monitors the quality and quantity of dental care, infection-control procedures, and other aspects of clinic operation.

All dental staff members are required by the National Commission on Correctional Health Care to have 12 hours of continuing education annually. The State Board of Dental Examiners also has a requirement that all dentists and dental hygienists have 36 hours of continuing education in each three-year period. UTMB is an approved provider of continuing education by the State Board of Dental Examiners. UTMB strives to provide continuing education at little or no cost to staff members.

The starting annual salary for a full-time registered dental hygienist is $35,000. Benefits include: eight hours of sick leave per month, group health insurance, 10-12 paid holidays per year, and a state retirement plan. Paid vacation time accrues at the following rate:

Less than 2 years 10 hours per month

2 but less than 5 years 11

5 but less than 10 years 12

10 but less than 15 years 13

15 but less than 20 years 15

20 years and more 17

Correctional dental hygiene is a growing field for dental hygienists that offers new opportunities for developing and implementing community-based programs. It`s a challenge to a hygienist`s clinical skills as well as her ability to communicate with and motivate people. It`s a unique and challenging career where many dental hygienists, including me, choose to practice.

Pam Myers is the dental hygiene coordinator for the University of Texas Medical Branch, Correctional Managed Health Care in Huntsville, Texas. She can be reached at (409) 437-3656, or by fax: (409) 437-3638.

Correctional Managed Care:

A win-win solution

In 1850, there were three "offenders" in what is today the Texas Department of Criminal Justice. Since 1957, when the offender population totaled 10,000, the inmate population of the TDCJ has shown explosive growth. By 1991, the inmate count had reached 50,516. In mid-1998, the count had reached 146,355 and still climbing!

This unprecedented growth prompted legislative action in 1994 to meet the need for the delivery of quality health care to inmates. The managed-care system established for inmates of the TDCJ is proving to be a win-win solution.

For the TDCJ, the managed-care system:

* Affords offenders access to a statewide network of health-care professionals, which was needed to cope with the system`s expansion

* Provides access to necessary, credible, quality health care

* Represents a cost-effective means of obtaining the required services

* Shares the risks (both financial and legal)

For the University Academic Health Centers, the managed-care system:

* Provides an expanded clinical teaching base

* Affords placement opportunities

* Adds a financial support base

* Increases the value of added services provided to the state, assisting the staff not only in the health and education missions, but also in the criminal- justice mission.

Taxpayers benefit through cost savings.

Offenders receive quality care in a timely, cost-effective, and efficient manner.

Click here to enlarge image

A death row inmate is prepared for dental treatment at the Ellis I dental clinic in Walker County, Texas.