Inside Job

The corridor leading to the health services wing of the New Hampshire State Prison for Men in Concord is cool, almost chilly—intentionally so, to help calm any jitters as inmates head to a medical procedure or a visit to the dentist. Once inside the dental clinic, though, the scene is fairly unremarkable: a small waiting area, four open-bay operatories, dentists and assistants hovering over patients as soft rock plays in the background, punctuated every so often by the whine of the drill.

But the young man awaiting his turn is wearing an orange jumpsuit. Supplies—whether syringes, Lidocaine capsules or just gauze—are under lock and key. During the exam, equipment is kept behind the patient, out of his reach, rather than on a bracket table. Before a patient can leave, there’s a careful accounting of all the instruments. And no one gets a floss sample because as important as it is to oral health, floss is contraband in a prison cell.

These small details are among the things that set prison dentistry apart from other kinds of practice. It may seem like a confounding mix of the familiar and the peculiar. But those who do it say it becomes a dental job like any other: your patients need your help; you’re there to improve their oral health, and, more often than not, to put a stop to their pain. The ever-present mindfulness about security becomes unremarkable, and the protocols of providing treatment behind bars become part of the work routine.

“I know that look when you first walk in and hear that door slam. I was like that, too, at first,” says Edward Dransite, D85, chief dental officer for the New Hampshire Department of Corrections. “Then it just becomes second nature, like everything else.”

Dentists choose this work for any number of reasons: freedom from the business chores and financial risk of running a private practice; opportunities for part-time employment and family-friendly hours; the chance to gain experience as a young professional or stay involved after closing a practice.

And there’s the element of caring for an underserved population, one for which oral health care has been particularly lacking. “It’s self-serving to have a job, yes, but I knew I was really providing a very valuable service, and that was important to me personally,” says Susan Albert, D78, who has worked intermittently at several maximum- and medium-security Massachusetts prisons over the past 13 years, including Cedar Junction, Bay State and Norfolk. 

Your Patients Are Criminals

Working in a prison isn’t for everybody. Doubtless, there are those who would chafe under the rigid structure that governs so much of the day. Dentists who have worked in state corrections systems also point to other issues, ranging from cutbacks in state funding, to frustrating bureaucracy, to shifting priorities from the contractors who manage the dental facilities. (Most states outsource dental and medical services.) A staff dentist may not receive benefits and may have to pay out-of-pocket for insurance and licensing, although some prison systems offer fairly thorough benefit packages.

Dental instruments, which are counted after every patient, are kept well out of reach of the inmates. Photo: Kelvin Ma

And then, there’s the not inconsiderable issue of knowing that the person in your chair has been found guilty of a crime—perhaps something unthinkably violent.

“When I treated them, I tried to never, never find out what they did for a crime,” says Roland H. Bryan, D91P, a dentist who had worked at the New Hampshire prison and is a former assistant clinical professor at Tufts School of Dental Medicine.

Bryan is not alone in those thoughts. Albert, for example, is an Orthodox Jew whose lifestyle outside the office keeps her fairly insulated from popular culture. “I don’t pay attention to the media, which, for me, is an advantage,” she says. Prison dentists repeat similar observations about their inmate-patients: “I’m not judgmental.” “They’re human beings, too.” “Sometimes you’re in the wrong place at the wrong time.”

Most times, Bryan says, it’s best to just focus on the task at hand. He recalled treating an inmate who had been convicted of a notorious murder. “I didn’t look at him. I just looked at his tooth. I had to sort of disassociate myself,” he says.

The prison dentists note that the state and federal corrections systems have a legal obligation to provide health care for inmates, based on the constitutional prohibition against “cruel and unusual” punishment, and, often, on specific court orders.

Another way to look at it is this: “Every human being deserves basic health care,” says William Del Gizzo, D85, chief of dental services for the Rhode Island Department of Corrections. “[The inmates] have had their issues on the outside; they’re doing their time here … but we don’t punish people by withholding health care.

“We’re a great triage for the public health system,” he adds. Once they’re released, inmates with long-festering, untreated oral health problems would likely end up as uninsured patients in local emergency rooms or draw on public assistance programs, such as Medicaid, for dental work.

“Either you can pay when they’re locked up, or pay when they’re on the street,” Del Gizzo says. “We’re a big part of the public health system, but nobody recognizes that.”

The prison dentists say that most inmates are incredibly grateful patients.

“Inmates are the most appreciative,” says Kunio Chan, D04, who worked in the Rhode Island prison from 2004 until this year. “You’ve helped them get rid of pain and given them the kind of examination they never had on the outside. Sometimes you’re the only dentist they’ve had in their lives.”

“They’re very polite and very happy with whatever we can do for them,” says Del Gizzo. “Even the littlest thing, like teaching them how to brush their teeth, is a big thing. They’ll sit in the chair, sometimes for hours, with a student extern, and then they’ll immediately get up and thank the student.”

Some Tufts graduates have found their way into prison dentistry through the school’s externship program, which offers five-week training experiences at the prison systems in both New Hampshire and Rhode Island. The prisons have been externship sites for at least two decades, with the number of students varying over the years. Recently, as many as 15 to 20 Tufts students have trained in prisons each year.

The student feedback has been mostly positive, says Cynthia Yered, D90, who directs the externship program. Working with a prison population presents dental students with challenges they may not have encountered before, she says.

“The Tufts dental students have a great resource at the prison regarding restorative opportunities,” says Dransite. At the dental school’s in-house clinics in downtown Boston, “most students have not seen patients requiring such extensive restoration of multiple decayed teeth,” he notes.

Victor Stetsyuk, D12, completed an externship at the New Hampshire prison in August. “The first thing that I’m learning is speed,” he said, two weeks into the experience. “You have to work fast and more confidently. That’s a big difference from the [dental school] clinic. There we book patients for three-hour appointments, and you have to be your own assistant, and you have to constantly find a professor to check your work.”

Good First Job

Edward Dransite, D85, chief dental officer for the New Hampshire Department of Corrections, left, and Victor Stetsyuk, D12, treat a patient. “The actual dentistry itself is not really different than on the outside,” Dransite says. Photo: Kelvin Ma

In private practice, getting a patient in and out of the chair in a timely fashion makes good business sense. “When you go into private practice, you usually start as an associate, where the main thrust is production, production, production,” Dransite says. “There is quite a bit of stress, and most fresh graduates are not paid a salary, but a percentage of collections, or of production, if you’re lucky.”

That’s one reason, Dransite says, that prison work is a good first job for a dental school graduate. Prison staff dentists are paid an hourly rate, roughly $60 to $72, based on experience. In the New Hampshire corrections system, benefits include malpractice insurance, retirement plan, subsidized health insurance, paid holidays, earned paid days off and continuing education benefits. “Ultimately, you may not be making as much as you could in the private sector, but you don’t have the pressure of having to sell dentistry,” Dransite says.

That was the attraction for Chan, who did his externship in Rhode Island and was asked to stay after graduation. “Even though it doesn’t pay as much as private practice, it was fixed pay and fixed hours,” he says. The job also offered a degree of flexibility that working in private practice wouldn’t have.

And “it was a chance to get my feet wet,” gaining additional experience with extractions and fillings and learning new things, he says.

Despite the considerable differences in workplace environment, “the actual dentistry itself is not really different than on the outside,” says Dransite, who was an assistant clinical professor of restorative dentistry at Tufts for 10 years and is now an assistant clinical professor in the department of public health and community service. “You have a chair-side assistant; you use the same materials; you do things the same way you were taught in dental school. The difference is that here, we keep any kind of treatment plan down to the bare necessities rather than trying to rehabilitate the whole mouth.”

A Different Philosophy

The rules governing what kinds of dental treatment inmates receive vary by state and are also different in the federal prison system. Some states use the guidelines set forth by publicly funded health plans, such as Medicaid or MassHealth.

For instance, Dransite says, “on the outside, if someone came in with meth mouth”—the rampant cavities that develop among users of methamphetamine—“we would do a lot of root canals. We might try to do posts and crowns and restorative dentistry. Here, we’ll restore the teeth we can with fillings, and the ones we can’t, we’ll extract, and the patient will receive a removable prosthetic.

“That takes a certain change in philosophy from dental school, where we were taught to save every tooth,” he notes. “Here you can’t. Everything has to be triaged, and you have to figure out the best treatment from there. Our clientele come in with great dental needs. Most have neglected their dental health, for whatever reason.”

While detailed data on the oral health of U.S. prison inmates is scarce, evidence indicates that it mirrors that of lower socioeconomic groups in the general population: extensive cavities and periodontal disease are significant issues.

“Dental care is listed as an essential health service by the National Commission on Correctional Health Care; nonetheless, the oral health of prisoners is generally poor,” according to an editorial published in the October 2005 issue of the American Journal of Public Health. A 2003 survey of inmates in Maine found that smoking-related ailments and dental pain were the most commonly reported health problems, after mental illness and substance abuse.

Of course, substance abuse and other environmental factors, such as poverty and poor nutrition, are intricately tied to oral health. Over the past decade, prison dentists have seen increasingly more incidences of meth mouth. Also prevalent is periodontal damage caused by cocaine use, including the practice of rubbing the drug along the gum line, which causes ulcerations of the gums and underlying bone. Chan remembers one patient who had necrosis of his nasal cavity that extended to the roof of his mouth as a result of cocaine abuse.

“They’ll tell you all about [their drug abuse] once they’ve cleaned themselves up and they’re not addicted anymore,” Dransite says. “They’ll take a different perspective: now they want their teeth taken care of, even though they’ve neglected them over the years.”

In the 25 years that he’s been a prison dentist, Del Gizzo says he’s noticed a gradual improvement in Rhode Island inmates’ oral health, which he attributes to increased fluoridation, better oral health education and wider access to dental insurance. “There are fewer and fewer who need dentures than there were 25 years ago,” he says.

Prison dentists are also well aware that some inmates fake a toothache to acquire painkillers—a phenomenon not limited to the prison population.

“We have patients who come in self-diagnosed, reporting, ‘I have a dry socket’—they’ve got all the terminology down,” says Dransite. “Some of them are repeaters on that, but eventually we get to know who they are. And some of them have a technique called ‘cheeking’—they’re not getting the pills for themselves. They’re pretending to swallow [them], and they’ll sell or trade them later. So, we’re not very big on giving out pain meds—even Motrin can be used as a bargaining tool.”

Albert said that the strict controls on prescription painkillers often discouraged inmates with real dental problems from seeking care. “They knew they were going to be turned down for drugs and were afraid that they were going to be in pain afterward,” she says.

In this world ruled by boundaries, the relationship between doctor and patient is more uneven than on the outside. Albert says she would set the tone by saying ‘You may be an inmate [in the rest of the prison], but when you cross that threshold, you are my patient.’

“I always called them ‘mister,’ never by their first names,” she says. “There was a mutual respect.”

But there is also the acknowledgment that the dentist ultimately has authority over the inmate. “They know that if they misbehave, they may not be able to come to dental for a while,” says Dransite. “If they want their teeth taken care of, they best be on their best behavior.”

Physical harm is seldom a threat under the highly controlled conditions inside a prison. Yered, the externship director, says students, particularly women, are sometimes hesitant to take the prison assignment precisely because they’re uneasy about their safety. Yet as one student reported on an externship evaluation: “The inmates do not cause any trouble. Don’t be scared of them because they want to see you to get rid of their pain.”

“I never felt threatened at all,” says Chan. In fact, most inmates have learned how to work the prison system, and know that being cooperative is the best way to get what they want. “They say the squeaky wheel gets the grease, but not in a prison,” Albert says. “I have to say, murderers make the best patients,” she adds matter-of-factly. “They are resigned to their fate, and they become very passive.”

And even tough guys have their weaknesses. Albert remembers a corrections officer bringing in one patient who had a reputation as a rough character—and he was absolutely huge. But the petite Albert wasn’t the one who was sweating: “Turns out, he was scared of the dentist.”

This story first appeared in the Fall 2011 Tufts Dental Medicine magazine.

Helene Ragovin, the editor of this magazine, can be reached at helene.ragovin@tufts.edu.