Risk Indicators for Dental Caries in Three Scottish Prison Populations

  • Tahira Akbar

Student thesis: Doctoral ThesisDoctor of Philosophy


One of the markers of the socioeconomic inequalities faced by prisoners is their experience of poorer health outcomes, including higher dental caries experience, when compared to the general population. Whilst, as a whole, prisoners are disparate there are also vulnerable sub-populations, including women, young offenders, and the elderly. There is scope to inform future health improvement programmes by characterizing how caries experience and related risk factors vary between prisoner groups. The aims of this thesis were to (1) review the literature reporting caries amongst prisoners, and (2) assess the disease burden and associated risk indicators in a population of Scottish prisoners.

Three data elements are reported: (i) a structured review with electronic searches of MEDLINE, Embase, Cinahl Plus, SCOPUS, PsychARTICLES, and ASSIA; (ii) selfreport data from a cross-sectional survey including measures for socio-demographics, medical and substance use history, dental anxiety (MDAS), mood (CES-D), and oral health-related attitudes and behaviours; and (iii) visual examination caries data which was evaluated using the International Caries Detection and Assessment System (ICDAS) and converted to the decayed, missing filled (DMF) index. The oral health survey was completed in a non-probabilistic stratified sample of 298 prisoners, held in three Scottish prison establishments, representative of females, long-stay adult males, and male young offenders.

From the 31 literature articles included, there were indications dental caries experience may have been historically underestimated since early stage incipient caries lesions were not routinely captured. The evidence predominantly centered on known risk factors for other health conditions in this population e.g. socioeconomic status, patterns of health service utilization and substance use. There is little empirical evidence for how risk factors for caries vary between prisoner groups.

In the Scottish prisons surveyed, overall prevalence of total obvious decay experience (D1MFT) was 97% and for caries into dentine (D3MFT) was 96% with high proportions across all three populations. Mean scores were 12.89, 13.87, and 8.10 for D1MFT, and 12.02, 13.28, and 6.20 for D3MFT, among females, long-stay adult males, and male young offenders respectively. Age-adjusted multiple regression analysis determined intravenous drug use was a significant (p < 0.05) risk indicator for both D1MFT and D3MFT scores among females and adult males, whereas other risk indicators varied between the two populations. Number of cigarettes smoked per day and dental attitudes also significantly explained both dental scores among females. For adult males, living in a non-stable living accommodation significantly explained higher D1MFT scores, and for D3MFT scores those who brushed their teeth with fluoride toothpaste at home had significantly lower scores whereas those who had attended the prison dentist had significantly higher scores. Additional risk factors for adult males included: sugar consumption at home, length of homelessness, and prison dental attendance for D1MFT; and length of homelessness and health condition(s) with shared common risk factors for D3MFT. The findings for male young offenders indicate prison dental attendance, and dental anxiety may explain caries outcomes however, combined with marital status, these explained less than 10% of the variance in dental scores.

This thesis has shown dental caries experience in Scottish prisoners is highly prevalent and future programmes should be prioritised for prisoners known to have a history of substance misuse or at risk of developing such dependencies. This work has also highlighted the participants had experienced non-stable accommodations just prior to prison, and had experience of care and instability in their social relationships, suggesting the ‘causes of the causes’ of health inequalities are existent for the Scottish prisons population. Therefore, there is a need to address both upstream issues, such as policies and strategies to reverse social and economic factors which cause health inequities, together with global downstream programmes for the wider prisons population. These downstream health improvement programmes should adopt a common risk factor approach and incorporate smoking cessation and peer group interventions to address dental-health related attitudes among females, whereas for males greater emphasis on securing community-housing is needed alongside interactive and tailored oral health educational programmes.
Date of Award2017
Original languageEnglish
SponsorsScottish Government
SupervisorRuth Freeman (Supervisor), Andrew Hall (Supervisor) & Sam Crouch (Supervisor)

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