Correspondence Address: Suyog Jain S/O Dr. Sunil Jain, Plot 212/A, House 108, Arya Nagar, Durg, Chhattisgarh - 491 001 India
Source of Support: None, Conflict of Interest: None
Aims: To help dentists to communicate with the hearing impaired patients, reach an accurate diagnosis and explain the treatment plan by learning some signs and gestures used in the nonverbal communication (NVC) and by devising some new signs and gestures related to dentistry which shall be easy to learn and understand both by the hearing impaired patients and the dentists. Settings and Design: The study was carried out on 100 hearing impaired students in the age group of 10–14 years in two special schools for hearing impaired children located in two different states of India, where different spoken languages and different sign languages are used. One dentist (expert dentist) was trained in the NVC and the other dentist (non expert dentist) had no knowledge of this type of communication, communicated the same sets of statements related to dentistry, to the hearing impaired children. One1 translator was assigned to judge their interactions. Students were asked to tell the interpreter at the end of each signed interaction what they understood from the statement conveyed to them by both the dentists. Statistical Analysis Used: All data collected were subjected to statistical analysis using Chi-square test and odds ratio test. Results: In the special school of 1st state, the nonexpert dentist conveyed only 36.3% of the information correctly to the students, whereas the expert dentist conveyed 83% of the information correctly. In the special school of 2nd state, the nonexpert dentist conveyed only 37.5% of the information correctly to the students, whereas the expert dentist conveyed 80.3% of the information correctly. Conclusions: Dentists should be made aware of the NVC and signs and gestures related to dentistry should be taught to the hearing impaired students as well as the dental students.
Keywords: Dental signs, hearing impaired, nonverbal communications in dentistry, special care dentistry
How to cite this article: Jain S, Duggi V, Avinash A, Dubey A, Fouzdar S, Sagar MK. Restoring the voids of voices by signs and gestures, in dentistry: A cross-sectional study. J Indian Soc Pedod Prev Dent 2017;35:115-22
How to cite this URL: Jain S, Duggi V, Avinash A, Dubey A, Fouzdar S, Sagar MK. Restoring the voids of voices by signs and gestures, in dentistry: A cross-sectional study. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2021 Jun 20];35:115-22. Available from: https://www.jisppd.com/text.asp?2017/35/2/115/206042
“The deaf community and the hearing community, there's not always a ton of interaction.”
About one in 600 neonates has a congenital hearing loss. Hearing impairment accounts to 1,261,722 with 5.76% of the total disability. It can result from prenatal and postnatal infections, anoxia, prematurity, exposure to ototoxic agents, and trauma. As the degree of loss increases, psychological, emotional, and social disturbances generally become more pronounced. Hearing impairment primarily influences communication, on which it can have a devastating effect.
It has been reported, a dental treatment is the greatest unattended health need of the disabled. Due to communication problems, it not only becomes very difficult fora deaf and mute child to approach the dental health-care provider, but also the dental health-care providers find themselves helpless in recording a proper history and explaining the treatment plan to these patients.
However, by being prepared, and by preparing the patient, health workers can ensure good communication, thereby giving patients access to appropriate and effective health care.
Therefore, this study is an attempt to bridge the gap between hearing impaired children and pediatric dentists which comprises of a two way communication where both the dentist and the patient interacts with each other. Such interactions will enable dentists to communicate with hearing impaired patients properly, reach an accurate diagnosis and explain the treatment plan by using some newly devised signs and gestures related to dentistry which are easy to learn and understand both by the hearing impaired patients and the dentists.
Subjects and Methods
A total of 100 institutionalized hearing impaired students aged 10–14 years from two different special schools located in two different states of India, Chhattisgarh and Andhra Pradesh were chosen. Hearing impaired children with any other disability or systemic disease were excluded from the study. The study included three different special schools for hearing impaired children, the Kopal Vani school (Raipur, Chhattisgarh), Prayas School (Bhilai, Chhattisgarh) and Sri Venkateswara High School for Deaf (Tirupati, Andhra Pradesh). These schools are located in Chhattisgarh and Andhra Pradesh state where different spoken languages, that is, Hindi and Telugu and different sign languages the National/Indian Sign Language and Local Sign Language are used, respectively.
In Kopal Vani School (Raipur, Chhattisgarh), one dentist was trained to interact with the hearing impaired children and so the term “expert dentist” was coined for him. This expert dentist along with the help of teachers well-versed with the National Sign Language framed a set of signed statements consisting of 15 signs and gestures related to common dental problems and treatment plans.
Then in Prayas School (Bhilai, Chhattisgarh), expert dentist along with another dentist termed as the “nonexpert dentist” (who had no prior knowledge of nonverbal communications [NVCs]) were made to interact individually with sixty students.
Expert dentist used the signs and gestures devised in the 1st school to check their effectiveness in the 2nd school, whereas the nonexpert dentist was asked to convey the same statements in a nonverbal and nonwritten format. One translator/interpreter was assigned to judge both of them and the students were asked to tell the interpreter at the end of each signed interaction what they understood from the statement conveyed to them by both the dentists. Data were recorded for each signed statement conveyed by both the dentists for each student.
Similar procedure was then carried out with 40 students of Sri Venkateswara High School for Deaf (Tirupati, Andhra Pradesh).
Figure 11: RCT (it is explained to general patients in layman term as “Curing the nerves of the tooth” so is explained in signs by showing the teeth followed by the signs of 'nerve' and 'cure/treatment')
All data collected were subjected to statistical analysis using Chi-square test and odds ratio test.
[Table 1] shows that in the special school of Bhilai located in Chhattisgarh state, when both the dentists individually interacted with the hearing impaired students by establishing the NVC (signed interactions) the nonexpert dentist was able to convey only 36.3% of the information correctly to the students whereas the expert dentist was able to convey 83% of the information correctly. This difference was statistically significant (<0.05) further the result of odds ratio shows that compared to the nonexpert dentist, the expert dentist is having 8.55 times higher odds for correct interpretations of his signed statements by the hearing impaired students.
Table 1: Comparison of interpretations of expert dentist and nonexpert dentist for overall signed statements in special school of Bhilai, Chhattisgarh
[Table 2] shows that in the special school of Tirupati located in Andhra Pradesh state, when both the dentists individually interacted with the hearing impaired students the nonexpert Dentist was able to convey only 37.5% of the information correctly to the students whereas the expert dentist was able to convey 80.3% of the information correctly. This difference was statistically significant (<0.05) further the result of odds ratio shows that compared to the nonexpert dentist, the expert dentist is having 6.8 times higher odds for correct interpretations of his signed statements by the hearing impaired students.
Table 2: Comparison of interpretations of expert dentist and nonexpert dentist for overall signed statements in special school of Tirupati, Andhra Pradesh
Hearing impairment can be congenital, inherited, or acquired throughout life as the result of accident, disease, drug-induced or as part of the aging process. Two main types of deafness may be described, conductive and sensory neural. The degree of hearing loss resulting from these impairments may range from slight (average loss not exceeding 40 db) to profound (average loss in the excess of 95 db) and may be unilateral or bilateral. Four degree of hearing loss were designated: Mild (26–40 db), moderate (41–70 db), severe (71–90 db), and profound (>90db).
Communication is a complex system of sending, receiving and interpreting messages. At its simplest it is a two-way process, involving a sender and a receiver. Communication can be described as: “A shared system of signals which requires systematic encoding and appropriate decoding of signals.” Skilled communication entails that the signal sent and the signal received are the same, regardless of the system of signals used, for example, language, symbols, or pictures.
Good communication is fundamental to good clinical practice. It is important as it allows us to inform, be informed and to exchange information – all important to understanding the patient's reason for attendance, their medical history, to explain treatment needs and gain informed consent, and to provide appropriate preventive advice. Good communication not only facilitates building of patient rapport and trust, it also helps to reduce patient anxiety and enhances patient satisfaction and compliance. Thus, for sound management of anxiety, building a sound rapport with the patient is a necessity, and for building the sound rapport with the patient, establishing a sound communication is the priority, all of this contributes to a better experience for the dental team as well as for the patient.
People with special needs including hearing impaired individuals encounter more barriers in receiving dental care than other people. They may have greater problems accessing dental care or may be at increased risk from dental disease. One of the greatest barriers the hearing impaired patients face in the dental office is their inability to express their complain. The majority have poor verbal skills and are restricted in their ability to communicate and convey their needs effectively. Furthermore, the lack of sign language awareness and training among health service staff creates significant problem for the patient in accessing health care and communicating with dentists.
There are three main elements of communication [Figure 16]: Words, tone of voice and body language. While words or verbal communication (VC) only account for 7% of transmission, tone of voice is estimated to convey 33% and body language or NVC 60% of the message. If VC and NVC are not congruent, it is the nonverbal elements (such as facial expression, body posture, and gestures) that will be believed. Sending “mixed messages” can lead to misunderstandings. Therefore, dentists need to be sensitive to NVC such as facial expressions, postures, and movements as a means of conveying feelings.
Deaf and hard of hearing people choose to communicate in different ways, depending on their level of deafness and who they are communicating with. They may use any, or any combination of, the following:
This is very tiring and requires a lot of concentration. It involves recognizing lip patterns, but is difficult as many sounds, such as “b” and “p,” have similar lip patterns.
This has its own structure and syntax. There are many sign languages such as the American Sign Language, British Sign Language (BSL), and Australian Sign Language, in India the National Sign Language also known as the Indian Sign Language is followed almost everywhere with Andhra Pradesh as an exception where Local/Regional Sign Language is followed.
Using the manual alphabet  where there are 26 different hand positions representing the 26 letters of the alphabet.
Hearing aids and cochlear implants
These can be very useful in making the most of any residual hearing but do not restore normal hearing. They will not necessarily make all sounds perfectly clear, they amplify all sounds and background noise can be a particular problem.
Some deaf people carry a Hearing Concern Sympathetic Hearing Card. Deaf people who have little or no effective speech are likely to use pen and paper.,
In the present study, of these 15 statements, signs for some common dental problems such as dental pain, swelling, broken tooth, decayed tooth, yellowish discolored teeth, bleeding from gums, halitosis, and mobility already existed in the National Sign Language.
Since the signs for treatment plans such as X-ray, restoration, RCT, extraction, scaling, orthodontic treatment, and brushing timings never existed before they were carefully developed by taking help from the teachers of the 1st special school (Kopal Vani School, Raipur, Chhattisgarh) who were expert in the National Sign Language and also by abiding to the Indian Sign Language Dictionary. The effectiveness or validity of all these signs were then assessed by establishing communication with the hearing impaired students of two different schools located in Chhattisgarh and Andhra Pradesh. Since the Sign Language of these two states have minor variations, some of the signed statements required slight modifications in the special school of Andhra Pradesh. These modifications were carefully made under the guidance of the teachers of that school who were expert in the Local Sign Language.
On extensive data search through MEDLINE, internet data and manual search no study was found which emphasized on the need of developing new signs and gestures, and learning the existing signs related to dentistry and hence that the agony of hearing impaired patients during their dental visits can be eased up. Therefore, this pioneer study aims to compare the effectiveness of transfer of information to the patient by a dentist expert in signed interactions against a nonexpert dentist, so that a set of some simple dental signs can be chalked out which will not only help dentists to understand the dental complains of such type of patients properly but also it will enable them to explain the treatment plan to the patient effectively, thereby building a sound doctor-patient relationship.
Champion and Holt  reported that two third of the hearing impaired children experience difficulties in communication at the dental visit, including being called from the waiting room, communicating with the dentist and/or nurse and understanding what will take place in the dental visit.
Royal National Institute for Deaf People's (2006) survey reported that 42% of deaf and hard of hearing people who had visited hospital (nonemergency) had found it difficult to communicate with staff. A 2014 report by Sign Health showed that eight in ten BSL users want to communicate using BSL, but that only one-third get the chance.
Another study reported that in the private and public health systems of Brazil there exists a considerable amount of communication gap between the patients and the hospital staff which leads to poor information exchange during the course of treatment, damage to the patient's autonomy, limits on their access to services, and reduced efficacy of therapy.
According to one case report an otherwise cooperate deaf and mute patient suffered iatrogenic trauma during enema insertion that required emergency surgical correction because his nurse had failed to establish a trusting relationship before the procedure. Ironically, the patient's physician had earlier easily performed digital rectal examination, a similar medical maneuver, with patient cooperation after establishing patient rapport.
Sfikas  reported about a judicial verdict of a medicolegal case which occurred in obstetrics practice in which a federal jury in Maine, US awarded $60,000 to a deaf man based on his claim that the practice unlawfully failed to provide interpreter services during his wife's pregnancy. The author insisted that the dentists must also provide effective communication, including supplying auxiliary aids and interpreter services as necessary to achieve effective communication when providing services to people with hearing impairments.
Dougall and Fiske  suggested that following points should be taken under consideration while dealing with a hearing impaired patient in dental office:
Position yourself with your face to the light so you can be seen clearly and face the patient so they can read your lips. Remove your facemask or wear a clear face shield to facilitate lip reading
If you are using communication support always remember to talk directly to the person you are communicating with, not the interpreter
Minimize background noise (such as music), distractions and interruptions
Allow extra time for the person to respond
If what you say is not understood, do not keep repeating it. Try saying it in a different way instead
Speak clearly but not too slowly, do not exaggerate your lip movements, and use natural facial expressions and gestures
Avoid jargon and unfamiliar abbreviations
Resist the urge to shout – it will not help, is uncomfortable for a hearing aid user and looks aggressive
Lower the pitch of your voice – it is more effective than raising the pitch as people lose high pitch hearing first
Use gestures for visual feedback, such as a thumbs up for “you are doing well”
Be prepared to write down what you have to say or have preprepared written prompts to save time
Check that the person you are talking to can follow you. Be patient and take the time to communicate properly
Make appointments and communicate with the patient through texting.
In our study, on comparing the results between the expert dentist and the nonexpert dentist in Bhilai (Chhattisgarh) school, significant difference was reported for all the signed statements except for the signed statement about “halitosis” and “brushing timings” [Table 3]. The reason for this could be attributed to the simplicity of sign, facial expression and gesture which even the nonexpert dentist was able to convey.
In Tirupati (Andhra Pradesh) school, significant difference was obtained for all the signed statements except for, “swelling,” “halitosis,” “rct” and “brushing timings.” The reason for “swelling,” “halitosis” and “brushing timings” could again be attributed to the simplicity of sign and also to the smaller sample size of the hearing impaired students in Andhra Pradesh School.
In Andhra Pradesh School seven out of forty students interpreted the expert dentist's signs regarding “RCT” correctly, although more number of students interpreted correctly the sign used by the expert dentist as compared to the nonexpert dentist, the result was statistically insignificant perhaps due to smaller sample size and variation in sign language.
For majority of the signed statements statistically significant difference was found on comparing the expert dentist's communication with that of the nonexpert dentist's communication both in Chhattisgarh and Andhra Pradesh schools, suggesting that there was better transfer of information when the expert dentist interacted with the hearing impaired children.
In both the schools, none of the students were able to understand or interpret the signs used by the nonexpert dentist about “decayed tooth,” “discolored/yellowish teeth,” “restoration,” “RCT” (except two students in Andhra Pradesh), “scaling” and “orthodontic treatment” suggesting that there is a strong need for the dental community to learn some basic and simple signs to improve their communication with such type of patients which will not only help in building a good patient rapport but will also reduce patient's anxiety level.
In comparison to the communication established by the nonexpert dentist, it was noted that the hearing impaired children were able to understand the signs used by the expert dentist more accurately as these signs were carefully devised under the guidance of sign language experts.
As already mentioned earlier that this is a pioneer study and no previous similar study was found, therefore it is recommended that further studies should be carried out in various locations to validate the effectiveness of the present study design.
Furthermore, dental signs need to be devised and standardized through proper channels, which can be taught to the hearing impaired students as well as the dental students so as to facilitate the communications which takes place between operator and the hearing impaired patient during treatment procedures because in our study we only concentrated on that part of the communication which is required only to understand patient's chief complain and explaining them the treatment modality.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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