Custodial Dental Care in Federal Courts: A Systematic Review of Appellate Decisions and Implications for Public Health

OBJECTIVES: To examine how federal appellate courts evaluate constitutional claims concerning custodial dental care and to characterize the clinical and procedural features of these cases. METHODS: Decisions of the U.S. courts of appeals issued between 1980 and 2025 were identified through structured database searches. Cases substantively evaluating dental care were coded for severe pain, infection, abscess (coded separately), functional impairment, delay, custody type, representation status, defendant level, and appellate outcome. Descriptive statistics summarized case characteristics, and logistic regression evaluated associations between selected variables and appellate outcomes. RESULTS: A total of 182 appellate decisions met inclusion criteria, of which 174 evaluated adequacy of care. Severe pain was described in 86% of coded cases and functional impairment in 62%. Infection was documented in 41% of cases, with an abscess specifically identified in 16%. Delay was alleged in 73% of cases. Overall, 35% of decisions resulted in reversal or remand. Among cases with documented delay duration, the median delay was substantially longer in plaintiff-favorable cases, and delays exceeding 90 days were associated with higher odds of reversal or remand. CONCLUSIONS: Appellate review emphasizes documented awareness and response rather than equivalence to community standards. This legal threshold does not ensure timely clinical resolution. Public health evaluation of custodial dental systems should consider disease progression and access to definitive treatment in addition to legal compliance. Improvements are likely to depend on system-level monitoring of access and timeliness of care rather than litigation alone, reflecting the distinction between legal sufficiency and clinical adequacy.