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Issues in Remediating a Correctional Dental Program, Shulman (9th Cir Corrections Summit), 2015

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Issues in Remediating a
Correctional Dental Program
Prepared for the 2015 Ninth Circuit
Corrections Summit, November 4-6, 2015
Jay D. Shulman, DMD, MA, MSPH
Adjunct Professor, Dept. of Periodontics
Baylor College of Dentistry

• Describe dental needs of correctional population
• Components of an adequate dental program
• Issues related to remediating and monitoring based
on experiences with Fussell and Perez
Settlement Agreement
 Selection and responsibilities of monitors
 Determining when substantial compliance is achieved

A Perfect Storm for Dental Disease
• More dental disease than free population
• Substantial pre-existing needs

Prisons take inmates as they are, not as they wish them to be
Staffing should accommodate high prevalence of dental needs

• Caries – risk factors: diet, substance abuse, polypharmacy

Many drug classes cause dry mouth which promotes decay

• Periodontal disease – risk factors diabetes, poor oral hyg.
• Edentulism – high prevalence of tooth loss
• Oral cancer – risk factors: race, tobacco, age

Adequate Dental Program
• “Consistent with generally accepted professional
standards … not limited to extractions … timely”
• Diagnosis: caries, periodontal disease, oral cancer
• Treatment should include continuum of care:
Extractions, fillings, removable dentures and limited
 Urgent care (toothaches) – timely pain relief
 Routine – untimely treatment may result in tooth loss
 Pain relief when clinic is closed (access to mid-levels)

Systemic Issues
• Care adequate in quality and quantity

Diagnosis consistent with professional standards
Scope of care - basic dental needs (a prison is not a health spa)
Institutional (public health) versus private practice model

• Timeliness (requires adequate access)

Toothaches – pain relief and treatment by dentist
Understaffed programs focus exclusively on toothaches

• Qualified providers (dentists, hygienists, assistants)
• Adequate policies and procedures

Settlement Agreement
• Process for selecting dental experts / monitors
• Process for dealing with expert disagreements
• Chief Monitor in multi-disciplinary cases?

Stand-alone dental, health care, or conditions of confinement
Fussell (Ohio) versus Perez (California) models

• Reporting requirements for experts
• Coordination with other cases (e.g., Perez)

Settlement Agreement (cont.)
• Specify resources, personnel and organizational structure
• Process to develop audit instrument
• Implementation timetable

Deviations require explanation
Phased implementation for large systems

• Specify ‘goal posts’ (or a process to develop them)
• Operational definition of substantial compliance based on audits
and other mandated changes

Audit Instrument
• Based on policies and procedures; approved by parties

Cast elements into binary questions
Several sections with different passing scores

• Agreement as to passing scores for each section
• Clear record selection rules
• Process for test audits and adjustments

Time consuming – may require several iterations

• Written report to parties

Experts / Monitors
• Must have confidence of parties and Court

An evolutionary process

• Must not lose sight of role – goal is an adequate, not a
perfect system
• Be prepared to serve as consultants to program if asked
• Should have ‘reasonable’ access to:

Reports and facilities
Dental providers (including contractors)
Custody (to look at pass system, escort process)

Perez / Fussell Remediation Lessons
• Two experts – one nominated by each party
• Initial contentious phase (“getting to acceptance”)
• Stable, experienced program leadership who are dentists
• Collaborative approach among experts and parties

Extensive interaction between experts and program leadership

• Critical that there is no disagreement over ‘facts’

Program staff participate in prison visits and audits
Opportunity to review draft reports (to identify inaccuracies)