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The Performance of a Screening Test for Urgent Dental Treatment Need In The performance of a screening IN BRIEF • Highlights the diffi culties in undertaking RESEARCH research in prisons. • Screening prisoners for dental conditions test for urgent dental treatment in ‘high turnover’ prisons is not effective. • Details the reasons why prisoners are a need in a prison population high need, diffi cult to engage population. K. M. Buchanan,1 K. M. Milsom,2 L. Zoitopoulos,3 A. Pau4 and M. Tickle5 Objective To compare the performance of a questionnaire-based assessment of dental pain delivered by non-dental prison nursing staff against a clinical examination performed by an experienced prison dentist (gold standard). Set- ting The research fi eldwork took place in the healthcare department at HMP Brixton located in South London. Methods The cohort were those who had complained of dental/facial pain to the prison authorities and were therefore placed on the waiting list for emergency dental care. Subjects were asked to complete the screening test and were then clinically examined by trained and calibrated dentists. The screening test was in the form of a 12-item questionnaire designed to categorise a population reporting dental pain into one of three groups. The screening test results were compared with the diagnosis of a clinical examination. Results Ninety-six subjects were recruited during the 16-week study period. Of the 96 prisoners recruited, 27 of those failed to complete the screening test and/or the diagnostic examination even though they had reported pain previously . When sensitivity and specifi city values were calculated for the 96 prisoners recruited, the sensitivity was fairly high (81%) and the specifi city was poor (33%). However, when these values were calculated for the sub–population, those that completed both the screening test and diagnostic examination (n = 69), the sensitivity did not improve particularly (83%) but the specifi city value fell substantially to 13%. Conclusions This study highlighted the problems of conducting research in the prison environment, for example increased security preventing researchers from gaining access into the prison and general pressures on prison staff. Additionally, the study demonstrated that screening is not effective in local prisons with a high turnover of prisoners. INTRODUCTION National Health Service (NHS). To sup- provide fast track access to dental serv- In 2003 the responsibility for funding port this process, in April 2006 primary ices for those screened positive. There prison health services in England was care trusts (local NHS bodies) were given are 24 and 48 hour general health checks transferred from the Home Offi ce to the responsibility for commissioning prison for newly admitted prisoners performed Department of Health. This was the fi rst health services and are now expected to by a nurse but there is no standardised step in a process of integrating prison ensure that prison health care is equiva- dental component to these assessments. health services into the mainstream lent to mainstream NHS services.1,2 A simple-to-complete questionnaire Many prison dental services are over- (Dental Pain Questionnaire (DePaQ)) stretched and this service is a signifi - has been developed and tested in the 1* 2 Research Manager, Consultant/Honorary Senior Lec- cant concern for PCTs and providers of NHS.7 This screening instrument clas- turer in Dental Public Health, Oral Health Unit, National Primary Care R&D Centre, University of Manchester, prison healthcare. Prisoners have high sifi es patients with dental pain into Higher Cambridge Street, Manchester, M15 6LP/Halton levels of untreated dental disease3-6 and three groups of common dental pain & St Helens Primary Care Trust; 3Consultant in Special Care Dentistry/Honorary Senior Lecturer in Special extensive oral neglect is common in conditions: Care Dentistry, Kings College London Dental Institute, newly admitted prisoners.2 Due to the Group 1 (acute periapical periodonti- Caldecott Road, London, SE5 9RW; 4Senior Lecturer, • Centre for Oral Adult Health, Barts and The London, extensive and unpredictable mobility tis and irreversible pulpitis) Queen Mary’s School of Medicine and Dentistry, Turner of remand and short stay prisoners and Group 2 (reversible pulpitis and den- Street, London, E1 2AD; 5Professor of Dental Public • Health and Primary Care, Oral Health Unit, National the restricted provision of dental serv- tine hypersensitivity) Primary Care R&D Centre, University of Manchester, ices in prisons, patients with toothache Group 3 (pericoronitis). Higher Cambridge Street, Manchester, M15 6LP • *Correspondence to: Miss Katie Buchanan can experience diffi culties in gaining Email: [email protected] rapid access to dental care.1 One possi- In a population attending an NHS Online article number E19 ble solution to this problem is to screen dental teaching hospital, the DePaQ was Refereed Paper - accepted 11 July 2008 new prisoners on entry to the prison capable of correctly classifying 89.7% of DOI: 10.1038/sj.bdj.2008.950 ©British Dental Journal 2008; 205: E19 for urgent dental treatment needs and dental pain cases initially categorised by BRITISH DENTAL JOURNAL 1 © 2008 Macmillan Publishers Limited. All rights reserved. RESEARCH clinical diagnoses. The respective sensi- tivity and specifi city values of the ques- 96 prisoners reported having dental pain to the prison authorities, were subsequently tionnaire were Group 1: 0.80, 0.83, Group placed on the urgent dental treatment waiting list consented into the study period 2: 0.85, 0.89, and Group 3: 0.59, 0.90. If this tool can perform to a similar level in a prison population it has the potential 5 of the 96 subjects reported not having pain at the screening test to rapidly identify prisoners reporting pain who have an urgent treatment need without the need for all prisoners to see a dentist. This possibility could improve 7 of the remaining 91 subjects failed to complete the screening test questionnaire the lives of prisoners and help PCT and prison healthcare mangers plan dental service resources more effi ciently. 15 of the remaining 84 subjects reported having no pain at the diagnostic examination stage The aim of this study was to assess the performance of the DePaQ in iden- tifying prisoners with an urgent need 69 subjects reported having dental pain and completed both the screening test for dental care when compared against and diagnostic examination, completed a questionnaire and a clinical examination clinical diagnoses. METHODS Fig. 1 Flow diagram of prisoners through the study The study population was composed of male prisoners providing informed con- 3. Pericoronitis (infl ammation con- in which two of the authors (LZ & AP) sent on the urgent treatment list of HMP nected to a partially erupted tooth, agreed the examination protocol and Brixton in London. All of these prison- classically a wisdom tooth). diagnostic criteria for the common den- ers had complained of toothache to the tal pain conditions using case scenarios prison authorities previously and were Those subjects that had no pain, or in a classroom context. This was fol- listed to have rapid access to the dental the questionnaire was incomplete or lowed by a calibration exercise in which service in prison, which provided dedi- they did not complete a clinical exami- 25 patients were examined and diag- cated sessions to see prisoners complain- nation, were classifi ed into a separate nosed prior to the start of the study and ing of pain. The prisoners were invited group (group 4). Subjects categorised there was 100% agreement between the to participate by a trained member of into groups 1 (irreversible pulpitis, acute dentists. The outcome of each diagnostic the healthcare team when they arrived periapical periodontitis) and 3 (pericoro- examination was recorded on a simple at the dental department. HMP Brixton nitis) were adjudged to have an urgent clinical data collection form. The den- serves a number of courts in the London need of treatment, while those in the tists categorised the study population conurbation and houses a mixture of group 2 and group 4 were defi ned as into the same clinical groupings as the male remand and sentenced prisoners.8 having non-urgent treatment need. screening test. This prison houses up to 798 prisoners Due to the high levels of literacy prob- Analysis included simple frequency at any one time, with an a high turnover lems among prisoners,10 the question- distributions and cross tabulations. of prisoners, many staying just 35 days naire was read out to prisoners by the Responses to the questionnaire were on average.9 nurse who normally undertakes the 48 entered into classifi cation equations from Ethical approval was granted by South hour general assessment of new prison- a previous study using a dental hospital Essex Local Research Ethics Committee. ers. The language used to introduce the setting. Using these classifi cation equa- Prisoners are considered a vulnerable questionnaire and used in the question- tions, each prisoner was assigned to one group. The NHS ethical review process is naire itself was piloted with nursing of the three groups of clinical conditions in place to protect research participants staff and prisoners in HMP Brixton. and then recategorised into urgent or and the researchers. The conduct of the The prison nurse recorded the prisoner’s non-urgent groups. Cross-tabulations study ensured that prisoners were nei- response to each question on the ques- between questionnaire classifi cation ther coerced nor offered any incentive tionnaire, which took approximately and clinical diagnosis were carried out to participate. fi ve minutes to complete. to compute sensitivity and specifi city The screening test was in the form The diagnostic test consisted of a his- values for: of a 12-item questionnaire designed to tory and clinical examination defi ned • The whole population, that was all categorise a population reporting dental by a diagnostic protocol. Two experi- individuals consented into the study pain into three groups: enced prison dentists were trained in • A subpopulation, which comprised all 1.
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