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California DOC Stipulates to Providing Comprehensive Dental Care Program

by John E. Dannenberg

In settlement of a federal class action lawsuit on December 15, 2005, the California Department of Corrections and Rehabilitation (CDCR) agreed to provide dental care for all prisoners as set forth in a new Dental Policies and Procedures manual (?Manual?) and an Implementation Plan.
CDCR?s watershed program covers all aspects of dental care from cleaning to root-canals and may well serve as a model for all detention systems.
At the very least, it is a complete turnaround from only providing extractions, and even then, possibly at the peril of death from ensuing untreated infection (see: PLN, Apr. 2005, p.20).

Carlos Perez, incarcerated at CDCR?s maximum security Salinas Valley State Prison, was the named plaintiff in a statewide class-action dental health care complaint filed by attorney Alison Hardy of the venerable Prison Law Office. The class is comprised of all CDCR prisoners who have ?serious dental care needs.? The complaint was filed accompanied by a settlement agreement (including attorney fees), which had been pre-negotiated with defendants James Tilton (CDCR Secretary), Peter Farber-Szekrenyi (Chief, CDCR Health Care) and William Kuykendall (CDCR Chief Dentist). Because CDCR medical care services were already under federal receivership (see: ?Federal Court Seizes California Prisons? Medical Care; Appoints Receiver With Unprecedented Powers,? PLN, Mar. 2006, p.1), CDCR was already ?softened up? to settle rather than suffer the ignominy of another federal court take-over. The Settlement implements the 170-page Manual and eight-page Implementation Plan. The latter outlines milestones of a staged ?rollout? to provide the requisite services at all 34 CDCR prisons by 2010. In addition, the court appointed experts to monitor the program.

Outline of Settlement

The Settlement requires the following general performance. By June 1, 2006, CDCR shall complete a state-wide staffing study, and shall hire according to that plan. Effectively immediately, CDCR shall provide emergency dental care 24 hours/day, seven days/week. Emergency care is defined as that ?designed to prevent death, alleviate severe pain, prevent permanent disability and dysfunction, or prevent significant medical or dental complications.? Such emergencies shall be handled by physicians, either at the prison or in an outside hospital.

By December 31, 2006, CDCR shall complete implementation at every prison (both Reception Centers and Mainlines) of tracking requests for dental treatment [date requested, date scheduled, date of actual treatment or documentation of failure-to-appear]. Also, examinations and treatment shall conform to the Manual wherever the roll-out is then due, and otherwise shall conform as medically necessary [as determined by a dentist]. Each CDCR prisoner shall receive an orientation handbook; each new arrival shall get one within ten days. All prisoners dentally screened shall be prioritized for treatment per the Manual. The Settlement also includes a fourteen-point Audit Instrument which shall be used to monitor and score each prison.

The Manual is comprised of six sections. Prefatory legal definitions and authority are in section 1. Section 2 covers in detail the scope of services to be provided. Health and safety issues are covered in section 3, including infection control, dental instrument control and radiation (X-ray) protection. Section 4 sets forth standards for dental clinic administrative procedures.

Dental Clinic Operations are outlined in section 5. Here, day-to-day details are covered, including co-payment, priority passes to the clinic (?ducats?), scheduling, treatment prioritization, treatment plans, interpreter services, emergencies (and related equipment), continuity of care, medical orders, therapeutic diets, pharmaceuticals and access to care. Finally, health records for dental treatment are laid out in section 6.

Dental Services Covered

Examination of section 2 reveals the breadth of the new dental services plan. The fourteen subsections include initial Reception Center dental screening, periodic dental exams, periodontal (gum) disease treatment, prosthodontic services (e.g., ?partials?), restorative services (fillings), oral surgery, endodontics (root-canals), cast crown-and-bridges, implants, orthodontics (braces), health orientation/self-care and hygiene intervention.

Reception Center screening shall include X-rays, head/neck examination, oral hard/soft tissue evaluation, and oral cancer screening. A thorough examination of all teeth shall chart decayed, impacted or missing teeth, as well as the existence of any prosthetic appliances. Then a score shall be made of relative urgency of dental care need, and a prioritized (5-level) treatment plan generated.

Periodic exams require that each prisoner under age 50 receive a dental exam at least every two years, while those 50 and over shall be examined annually. Periodontal disease shall be coded (5 levels). Minimal disease shall be treated by plaque and calculus removal. More advanced cases may receive root planing and scaling, or surgical treatment. Particular care will be given pregnant prisoners to stem related medical complications. Prosthodontics shall be supplied (at prisoner expense, if not indigent) for those with at least 12 months left on their sentences.

Fillings shall be from amalgam, as the material of choice. Crowns may be provided where decay is not too advanced and prisoner hygiene is compatible. Oral surgery shall be provided promptly regardless of time left to serve, and may be directed to outside surgery facilities. Vital teeth are eligible for root-canal treatment at each dental clinic, where prognosis for the tooth is good. [This should save a lot of teeth which were formerly just extracted as the sole form of ?treatment.?]

Crown-and-bridge services are defined as ?excluded services,? i.e., not routinely provided. They (versus other techniques) must be approved by the Dental Authorization Committee, and then only upon recommendation of the attending dentist averring the need. Pre-conditions include available support teeth, demonstrated prisoner hygiene, and long-term prognosis of such an appliance for vital teeth. While dental implants, the ?gold standard? of tooth replacement, are not provided for in the CDCR dental plan, the plan provides that CDCR will establish a policy wherein prisoners may arrange for implants at outside providers, at prisoner expense. Finally, orthodontics are not provided by CDCR. A prisoner incarcerated while undergoing such treatment on the outside may arrange to have follow-up treatment outside at his expense. No new orthodontic treatment will be approved, however.

Prisoner Hygiene Encouraged

A prominent feature of the new plan is to measure and encourage good dental hygiene by prisoners. Hygiene is well known to be the best preventive dental treatment plan. Prisoners will be ?scored? by their plaque build-up records as a predicate for major non-emergency dental treatment. Grounded in common sense, good hygiene provides a strong incentive for prisoners to ?earn? the otherwise advanced treatment they need. In short, prisoners need to learn to take control of their oral hygiene; the plan will both encourage it via hygiene education and reward it through newly available restorative treatment protocols.

On August 21, 2006, the court approved the class action settlement. On September 25, 2006, the parties stipulated to $131,800.00 in attorney fees and costs incurred in the case through and including August 28, 2006. The fees were capped under the Prison Litigation Reform Act.

Prison health administrators nationwide would be well advised to study the new CDCR plan to formulate plans for their own jurisdictions. See: Perez v. Tilton, U.S.D.C., N.D. Cal., Case No. 3:05-CV-5241 JSW, Stipulation and Order).

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Related legal case

Perez v. Tilton