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Oral health needs of adolescents in a juvenile detention facility
Journal of Adolescent Health 38 (2006) 755–757
Adolescent health brief
Oral health needs of adolescents in a juvenile detention facility Kenneth Bolin, D.D.S.* and Daniel Jones, D.D.S., Ph.D. Baylor College of Dentistry, Dallas, Texas Manuscript received March 4, 2005; manuscript accepted May 31, 2005
Abstract
Oral health needs of adolescents in a large urban county juvenile detention facility were investigated using a retrospective chart review. Decayed, missing, and filled teeth (DMFT) data and other oral health indicators were abstracted from selected charts. A majority of detainees in this study had unmet dental treatment needs. © 2006 Society for Adolescent Medicine. All rights reserved.
Keywords:
Juvenile delinquency; Oral health; Dental caries; Adolescent health services; Prisoners
Although the prevalence of dental caries is declining among children and adolescents in the United States [1], it remains a significant problem in some populations, particularly certain racial and ethnic groups and poor children [2]. National data indicate that 80% of dental caries in the permanent teeth found in children is concentrated in 25% of the child and adolescent population [3]. Data from the Third National Health and Nutrition Examination Survey (NHANES III) describe and quantify the amount of dental caries, but do not include incarcerated persons who have been shown to have a high prevalence of medical conditions, including dental problems [4,5]. The prevalence of dental disease in incarcerated adolescents in the United States is largely unknown, but many youth entering detention lack comprehensive health care and have long-term neglected health needs [6], whereas the scope of the care offered by detention facilities varies widely. The vast majority of residents in juvenile residential placement (detention) facilities in October 1999, the latest data available, were juvenile offenders (81%). Juvenile offenders held for delinquency offenses accounted for 78% of all residents. Delinquency offenses are behaviors that would be criminal law violations for adults. Status offenders accounted for a small proportion of all residents (4%). Status offenses are behaviors that are not violations for adults, such as running away, truancy, and incorrigibility. Some resi*Address correspondence to: Kenneth A. Bolin, D.D.S., M.P.H., Department of Public Health Sciences, Baylor College of Dentistry, 3302 Gaston Avenue, Room 705, Dallas, TX 75246. E-mail address: [email protected]
dents were held in the facility but were not charged with or adjudicated for an offense (e.g., youth referred for abuse, neglect, emotional disturbance, or mental retardation, or those referred by their parents). Together, these other residents accounted for 19% of all residents. Nationwide in 1999, 371/100,000 juveniles in the population were held in detention; in Texas the rate was 370/100,000 [7]. This study was designed to determine the prevalence of dental disease in detainees of the Juvenile Detention Center in Dallas County, Texas. The research protocol, a retrospective chart review, received approval from the Baylor College of Dentistry IRB, and, because the study dealt with data already contained in dental charts, no informed consent was required by the Committee on Human Subjects. Data were collected and recorded in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Methods The Association of State and Territorial Dental Directors (ASTDD) manual of assessing oral health needs [8] was used in this study. The sample size was chosen to reflect a conservative anticipated population proportion with disease (experiencing one or more carious teeth) of 50% at a 95% confidence level, with a relative precision of 10% [9]. Records were chosen randomly from dental screenings (which are required for all detainees) performed from September 1999 through December 2003. Screenings consist of taking a medical history, asking if the patient has any complaint, visual examination of the teeth and soft tissues,
1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2005.05.029
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K. Bolin and D. Jones / Journal of Adolescent Health 38 (2006) 755–757
and charting of all findings. Interexaminer bias was controlled by randomly selecting the charts of patients aged 12–17 years, screened by the same dentist, to obtain a representative sample of the population profile for age, gender and ethnicity. Indicators of oral health such as caries experience (decay present or treated), need for extraction of unrestorable teeth, number of teeth with untreated decay, presence of gingivitis, calculus, number of sealants on molar teeth, and demographic data were selected for abstraction. Frequency analyses were performed on all demographic and oral health indicators. DMFT (decayed, missing, and filled teeth) and D/DMFT scores were calculated using SPSS-PC version 12™ (SPSS Inc., Chicago, Illinois). Urgency of treatment criteria were derived from classification of need described in the ASTDD Seven-Step Model: low urgency (no visible disease or incipient disease), moderate urgency (cavitated, asymptomatic decay or moderate gingivitis), and high urgency (infection, tooth or jaw fracture, pulpitis or severe periodontal conditions with bleeding). Results Of 419 subjects, 24.6% were female and 75.4% male, with an ethnic distribution of 45.1% African-American, 35.3% Mexican-American or Hispanic, 15.8% White, and 3.8% Asian or “other,” which was a representative sample of the yearly detention facility population. The median age of the subjects was 15.43 years with a mean age of 15.35 years (SE .06; SD 1.17). Dental caries experience was 74% and prevalence of untreated dental decay was 49.6%. The mean overall DMFT was 3.58 (SE .17; SD 3.39). The mean DT ⫽ 1.9, mean FT ⫽ 1.6, and mean MT ⫽ 0.06. The ratio of D/DMFT (when D ⬎ 0) was 0.79 (SE .02; SD .29). Preventive sealants on permanent molars were found in only 14.8% of the detainees. Group-wise comparisons for DMFT, DT, FT, MT, D/DMFT, and number of sealants found no statistical difference between male and female detainees. The comparison of DFMT scores for study subjects and age group/race-ethnicity matched subjects from NHANES III is shown in Table 1. Based on the urgency of treatment criteria used in this
Table 1 Mean (SE) DMFT comparison ages 12–17 [3] Ethnicitya
NHANES III
n
Dallas Co. detainees
n
All groups African-American Mexican-American White
2.8 (.2) 2.5 (.2) 2.8 (.1) 2.7 (.2)
1115 315 412 762
3.6 (.2) 3.4 (.2) 3.9 (.3) 3.4 (.4)
419 189 148 66
DMFT ⫽ decayed, missing, and filled teeth. a Using NHANES III classification.
Table 2 Percent of adolescents aged 15 years with dental caries experience [10] Ethnicitya
Dallas County detaineesb
Healthy People 2010 baselinec
Healthy People 2010 target
All groups Black Mexican-American White
74 74 80 61
61 70 57 60
51
a
Using Healthy People 2010 classification. Detainees mean age 15.4 years (SD 1.2) c Data from 1988 –1994. b
study, 80.7% of the study group had low urgency, 13.1% had moderate urgency, and 6.2% had high urgency of treatment need. A large group of patients (42.2%) had plaque accumulation and supra-gingival calculus sufficient to warrant professional plaque and calculus removal. Additionally, 87.6% needed dental sealants on the permanent molars, based on age, past and current history of decay, and overall caries risk. The mean DMFT of the study sample was higher than populations of the same age and race-ethnicity groups in noninstitutionalized NHANES III subjects. The history of dental decay component of the oral health status for our study group is compared with baseline data and goals of Healthy People 2010 in Table 2. Discussion Clearly, we can conclude that this “community” has experienced a low utilization of preventive or therapeutic dental services. Untreated decay totaled 79% of the DMFT score in those juveniles when D ⬎ 0. This is not surprising, because the majority of the detainees (84.2%) were of ethnic minorities, which are known to have higher dental disease experience than Whites in every age group [10]. The fact that over half of the adolescents detained have untreated decay compared with the national average of 20% is disturbing, and on any given day approximately 58 residents of the facility have moderate or high urgency of need for dental care. However, the presence or lack of urgency does not mean there is not need for preventive and therapeutic dental services. For instance, the Healthy People 2010 goal for children with sealants on molar teeth is 50%, but our study group was only 14.8%. If pit and fissure sealants were applied routinely to susceptible tooth surfaces in conjunction with the appropriate use of fluoride, most tooth decay in children could be prevented, because 90% of the decay in children’s teeth occurs in tooth surfaces with pits and fissures [10]. One limitation of this study is that any criteria developed for measuring dental disease is subject to clinical judgment of the dentist, perception of need by the patient or parent, and relative importance of oral health to government funding entities. Given the fact that all incoming detainees (⬇ 400/month) must receive a screening exam and all emer-
K. Bolin and D. Jones / Journal of Adolescent Health 38 (2006) 755–757
gent dental complaints be addressed, the dental component is largely precluded from delivering elective yet needed treatment for preventive services, untreated dental decay, and periodontal diseases. Additionally, because the average length of stay is 19 days (range ⬍ 1 day to ⬇ 6 months), completion of comprehensive treatment plans are rare in any but the most long-term detainees. A primary challenge in delivering dental services under such conditions is obtaining the greatest benefit for the most people with the available resources. Conducting a needs assessment is a necessary first step in program planning in such facilities.
References [1] U. S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2000. [2] Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988 –1994. J Am Dent Assoc 1998;129:1229 –38.
757
[3] Kaste LS, Selwitz RH, Oldakowski RJ, et al. Coronal caries in the primary and permanent dentition of children and adolescents 1–17 years of age: United States, 1988 –1991. J Dent Res 1996;75:631– 41. [4] Anderson B, Farrow J. Incarcerated adolescents in Washington State. J Adolesc Health 1998;22:363–7. [5] Joseph-DiCaprio J, Farrow J, Feinstein RA, et al. Health care for incarcerated youth. Position paper of the Society for Adolescent Medicine. J Adolesc Health 2000;27:73–5. [6] Council on Scientific Affairs. Health status of detained and incarcerated youths. JAMA 1990;263:987–91. [7] Sickmund M. Juveniles in Corrections. National Report Series Bulletin, Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice, June 2004 (NCJ 202885). [8] Association of State and Territorial Dental Directors. Assessing Oral Health Needs: ASTDD Seven-Step Model (revised edition). Jefferson City, MO: Association of State and Territorial Dental Directors, 2003. [9] Lwanga S, Lemeshow S. Sample Size Determination in Health Studies: A Practical Manual. Geneva: World Health Organization, 1991. [10] U.S. Department of Health and Human Services. Healthy People 2010, Volume II, 2nd edn, Part B: Focus Area 21, Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2000.
Adolescent health brief
Oral health needs of adolescents in a juvenile detention facility Kenneth Bolin, D.D.S.* and Daniel Jones, D.D.S., Ph.D. Baylor College of Dentistry, Dallas, Texas Manuscript received March 4, 2005; manuscript accepted May 31, 2005
Abstract
Oral health needs of adolescents in a large urban county juvenile detention facility were investigated using a retrospective chart review. Decayed, missing, and filled teeth (DMFT) data and other oral health indicators were abstracted from selected charts. A majority of detainees in this study had unmet dental treatment needs. © 2006 Society for Adolescent Medicine. All rights reserved.
Keywords:
Juvenile delinquency; Oral health; Dental caries; Adolescent health services; Prisoners
Although the prevalence of dental caries is declining among children and adolescents in the United States [1], it remains a significant problem in some populations, particularly certain racial and ethnic groups and poor children [2]. National data indicate that 80% of dental caries in the permanent teeth found in children is concentrated in 25% of the child and adolescent population [3]. Data from the Third National Health and Nutrition Examination Survey (NHANES III) describe and quantify the amount of dental caries, but do not include incarcerated persons who have been shown to have a high prevalence of medical conditions, including dental problems [4,5]. The prevalence of dental disease in incarcerated adolescents in the United States is largely unknown, but many youth entering detention lack comprehensive health care and have long-term neglected health needs [6], whereas the scope of the care offered by detention facilities varies widely. The vast majority of residents in juvenile residential placement (detention) facilities in October 1999, the latest data available, were juvenile offenders (81%). Juvenile offenders held for delinquency offenses accounted for 78% of all residents. Delinquency offenses are behaviors that would be criminal law violations for adults. Status offenders accounted for a small proportion of all residents (4%). Status offenses are behaviors that are not violations for adults, such as running away, truancy, and incorrigibility. Some resi*Address correspondence to: Kenneth A. Bolin, D.D.S., M.P.H., Department of Public Health Sciences, Baylor College of Dentistry, 3302 Gaston Avenue, Room 705, Dallas, TX 75246. E-mail address: [email protected]
dents were held in the facility but were not charged with or adjudicated for an offense (e.g., youth referred for abuse, neglect, emotional disturbance, or mental retardation, or those referred by their parents). Together, these other residents accounted for 19% of all residents. Nationwide in 1999, 371/100,000 juveniles in the population were held in detention; in Texas the rate was 370/100,000 [7]. This study was designed to determine the prevalence of dental disease in detainees of the Juvenile Detention Center in Dallas County, Texas. The research protocol, a retrospective chart review, received approval from the Baylor College of Dentistry IRB, and, because the study dealt with data already contained in dental charts, no informed consent was required by the Committee on Human Subjects. Data were collected and recorded in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Methods The Association of State and Territorial Dental Directors (ASTDD) manual of assessing oral health needs [8] was used in this study. The sample size was chosen to reflect a conservative anticipated population proportion with disease (experiencing one or more carious teeth) of 50% at a 95% confidence level, with a relative precision of 10% [9]. Records were chosen randomly from dental screenings (which are required for all detainees) performed from September 1999 through December 2003. Screenings consist of taking a medical history, asking if the patient has any complaint, visual examination of the teeth and soft tissues,
1054-139X/06/$ – see front matter © 2006 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2005.05.029
756
K. Bolin and D. Jones / Journal of Adolescent Health 38 (2006) 755–757
and charting of all findings. Interexaminer bias was controlled by randomly selecting the charts of patients aged 12–17 years, screened by the same dentist, to obtain a representative sample of the population profile for age, gender and ethnicity. Indicators of oral health such as caries experience (decay present or treated), need for extraction of unrestorable teeth, number of teeth with untreated decay, presence of gingivitis, calculus, number of sealants on molar teeth, and demographic data were selected for abstraction. Frequency analyses were performed on all demographic and oral health indicators. DMFT (decayed, missing, and filled teeth) and D/DMFT scores were calculated using SPSS-PC version 12™ (SPSS Inc., Chicago, Illinois). Urgency of treatment criteria were derived from classification of need described in the ASTDD Seven-Step Model: low urgency (no visible disease or incipient disease), moderate urgency (cavitated, asymptomatic decay or moderate gingivitis), and high urgency (infection, tooth or jaw fracture, pulpitis or severe periodontal conditions with bleeding). Results Of 419 subjects, 24.6% were female and 75.4% male, with an ethnic distribution of 45.1% African-American, 35.3% Mexican-American or Hispanic, 15.8% White, and 3.8% Asian or “other,” which was a representative sample of the yearly detention facility population. The median age of the subjects was 15.43 years with a mean age of 15.35 years (SE .06; SD 1.17). Dental caries experience was 74% and prevalence of untreated dental decay was 49.6%. The mean overall DMFT was 3.58 (SE .17; SD 3.39). The mean DT ⫽ 1.9, mean FT ⫽ 1.6, and mean MT ⫽ 0.06. The ratio of D/DMFT (when D ⬎ 0) was 0.79 (SE .02; SD .29). Preventive sealants on permanent molars were found in only 14.8% of the detainees. Group-wise comparisons for DMFT, DT, FT, MT, D/DMFT, and number of sealants found no statistical difference between male and female detainees. The comparison of DFMT scores for study subjects and age group/race-ethnicity matched subjects from NHANES III is shown in Table 1. Based on the urgency of treatment criteria used in this
Table 1 Mean (SE) DMFT comparison ages 12–17 [3] Ethnicitya
NHANES III
n
Dallas Co. detainees
n
All groups African-American Mexican-American White
2.8 (.2) 2.5 (.2) 2.8 (.1) 2.7 (.2)
1115 315 412 762
3.6 (.2) 3.4 (.2) 3.9 (.3) 3.4 (.4)
419 189 148 66
DMFT ⫽ decayed, missing, and filled teeth. a Using NHANES III classification.
Table 2 Percent of adolescents aged 15 years with dental caries experience [10] Ethnicitya
Dallas County detaineesb
Healthy People 2010 baselinec
Healthy People 2010 target
All groups Black Mexican-American White
74 74 80 61
61 70 57 60
51
a
Using Healthy People 2010 classification. Detainees mean age 15.4 years (SD 1.2) c Data from 1988 –1994. b
study, 80.7% of the study group had low urgency, 13.1% had moderate urgency, and 6.2% had high urgency of treatment need. A large group of patients (42.2%) had plaque accumulation and supra-gingival calculus sufficient to warrant professional plaque and calculus removal. Additionally, 87.6% needed dental sealants on the permanent molars, based on age, past and current history of decay, and overall caries risk. The mean DMFT of the study sample was higher than populations of the same age and race-ethnicity groups in noninstitutionalized NHANES III subjects. The history of dental decay component of the oral health status for our study group is compared with baseline data and goals of Healthy People 2010 in Table 2. Discussion Clearly, we can conclude that this “community” has experienced a low utilization of preventive or therapeutic dental services. Untreated decay totaled 79% of the DMFT score in those juveniles when D ⬎ 0. This is not surprising, because the majority of the detainees (84.2%) were of ethnic minorities, which are known to have higher dental disease experience than Whites in every age group [10]. The fact that over half of the adolescents detained have untreated decay compared with the national average of 20% is disturbing, and on any given day approximately 58 residents of the facility have moderate or high urgency of need for dental care. However, the presence or lack of urgency does not mean there is not need for preventive and therapeutic dental services. For instance, the Healthy People 2010 goal for children with sealants on molar teeth is 50%, but our study group was only 14.8%. If pit and fissure sealants were applied routinely to susceptible tooth surfaces in conjunction with the appropriate use of fluoride, most tooth decay in children could be prevented, because 90% of the decay in children’s teeth occurs in tooth surfaces with pits and fissures [10]. One limitation of this study is that any criteria developed for measuring dental disease is subject to clinical judgment of the dentist, perception of need by the patient or parent, and relative importance of oral health to government funding entities. Given the fact that all incoming detainees (⬇ 400/month) must receive a screening exam and all emer-
K. Bolin and D. Jones / Journal of Adolescent Health 38 (2006) 755–757
gent dental complaints be addressed, the dental component is largely precluded from delivering elective yet needed treatment for preventive services, untreated dental decay, and periodontal diseases. Additionally, because the average length of stay is 19 days (range ⬍ 1 day to ⬇ 6 months), completion of comprehensive treatment plans are rare in any but the most long-term detainees. A primary challenge in delivering dental services under such conditions is obtaining the greatest benefit for the most people with the available resources. Conducting a needs assessment is a necessary first step in program planning in such facilities.
References [1] U. S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2000. [2] Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988 –1994. J Am Dent Assoc 1998;129:1229 –38.
757
[3] Kaste LS, Selwitz RH, Oldakowski RJ, et al. Coronal caries in the primary and permanent dentition of children and adolescents 1–17 years of age: United States, 1988 –1991. J Dent Res 1996;75:631– 41. [4] Anderson B, Farrow J. Incarcerated adolescents in Washington State. J Adolesc Health 1998;22:363–7. [5] Joseph-DiCaprio J, Farrow J, Feinstein RA, et al. Health care for incarcerated youth. Position paper of the Society for Adolescent Medicine. J Adolesc Health 2000;27:73–5. [6] Council on Scientific Affairs. Health status of detained and incarcerated youths. JAMA 1990;263:987–91. [7] Sickmund M. Juveniles in Corrections. National Report Series Bulletin, Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice, June 2004 (NCJ 202885). [8] Association of State and Territorial Dental Directors. Assessing Oral Health Needs: ASTDD Seven-Step Model (revised edition). Jefferson City, MO: Association of State and Territorial Dental Directors, 2003. [9] Lwanga S, Lemeshow S. Sample Size Determination in Health Studies: A Practical Manual. Geneva: World Health Organization, 1991. [10] U.S. Department of Health and Human Services. Healthy People 2010, Volume II, 2nd edn, Part B: Focus Area 21, Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2000.