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Oral Health and Dental Care in Deaf and Hard of Hearing

Population: A Scoping Review
Valeria Camposa / Ricardo Cartes-Velásquezb / Michael McKeec

Purpose: To compile the literature available about the oral health and dental care of the deaf and hard of hearing
(DHH) population.
Materials and Methods: The study question of this scoping review was ‘What are the main findings reported in the
literature about oral health and dental care of the DHH population?’ The following databases were included: Web of
Science, LILACS, SciELO, MEDLINE, Scopus, EMBASE, GoogleScholar and Redalyc. Full-text articles published in
peer-reviewed journals, in Spanish, Portuguese, and English, from the January 2000 to January 2018 were se-
lected with qualitative and quantitative methods. All study designs were included in the review with the exception
of letters to the editor and case reports
Results: A total of fifty articles were selected for analysis. DHH population has poorer oral hygiene and a higher
prevalence of caries than their non DHH peers. DHH also report significant struggles with oral health and dental ac-
cess. Most dentists experienced difficulties communicating with their DHH patients
Conclusions: This scoping review is the first known that centers on DHH oral health and their dental care. Efforts
to develop accessible dental health programmes are needed to address apparent oral health inequities in the DHH
population.
Key words: communication aids for disabled, deaf, hard of hearing, hearing loss, persons with disabilities, special care

Oral Health Prev Dent 2020; 18: 417–426. Submitted for publication: 13.02.19; accepted for publication: 20.05.19
doi: 10.3290/j.ohpd.a44687

earing loss ranks third amongst disabilities.104 Accord-

H ing to its aetiology, it can be genetic, congenital or ac-
quired; according to its location, it can be classified as con-
more than 360 million people live with moderate to pro-
found hearing loss. There is a prevalence of 1.4% in chil-
dren between 5 and 14 years old, and about 10% among
ductive, sensorineural, mixed, or central. Hearing loss can people 15 years old and above. A greater proportion of deaf
range from mild (less than 40 dB) to profound (more than and hard of hearing (DHH) live in low- and middle-income
90 dB). Depending on the time of hearing loss onset, it can countries.85,105
be prelingual, perilingual, or postlingual, which means be- People with prelingual hearing loss often identify them-
fore, during, or after language acquisition,77,105 or later selves with the Deaf Community, a world with its own lan-
onset (e.g. post-educational or post-vocational). Worldwide, guage and culture.61 The Deaf Community has several dis-
tinctive characteristics, customs and values which have
emerged from their hearing condition. People in this com-
munity use sign language as their preferred method of com-
munication.37,43,105 Sign language differs from spoken lan-
a Assistant Professor, Department of Preventive and Public Health Dentistry, guages in its linguistic structure, is not universal,43,87 but
School of Dentistry, University of Concepción, Concepción, Chile. Study con- is recognised in more than 30 countries.26
cept and design, collected and interpreted the data, wrote and proofread the
manuscript, contributed substantially to discussion. DHH individuals are more likely to have lower socioeco-
b Associate Professor, Faculty of Dentistry, Universidad Andrés Bello, Concep-
nomic status, including lower household income, poorer
ción, Talcahuano, Chile. Study concept and design, interpreted the data, educational achievement, and higher rates of unemploy-
wrote and proofread the manuscript, contributed substantially to discussion. ment.17 Furthermore, DHH individuals are associated with
c Assistant Professor, Department of Family Medicine, University of Michigan a number of adverse health outcomes.34,99 Hearing loss
Medical School, Ann Arbor, MI, USA. Study design, interpreted the data, wrote
and proofread the manuscript, contributed substantially to discussion. represents a major communication barrier in health care
settings, impacting the quality of health care delivered to
Correspondence: Dr. Valeria Campos, Department of Preventive and Public individuals with hearing loss.13 This is cause for concern,
Health Dentistry, School of Dentistry, Roosevelt 1550, Barrio Universitario, Con-
cepción, Chile. Tel: +56-41-220-4232; since poor health care communication adversely affects
e-mail: [email protected] many health outcomes.13,48, 49 Many DHH individuals strug-

Vol 18, No 3, 2020 417

Campos et al

gle with lower health literacy and reading literacy level com- Data Source
pared to non-DHH persons, 14,47,94,68,100 further complicat- The databases were selected according to their coverage of
ing efforts to disseminate health information to this biomedical disciplines: Web of Science, LILACS, SciELO,
community. On the other hand, health personnel frequently MEDLINE, Scopus, EMBASE, GoogleScholar and Redalyc.
lack training to address the specific needs of this popula- Initially, no limits were set on date, language, type of arti-
tion (e.g. communication, culture), which leads to patient cle, country, or any other filter.
dissatisfaction, reduced health care accessibility, inade-
quate information, and lower health care education and Eligibility Criteria
communication quality.16,41,84 The following were included in the final analysis: full-text
Regular dental visits provide the basis of oral healthcare, articles published in peer-reviewed journals; in Spanish,
so it is important that dentists obtain basic knowledge and Portuguese, and English; from the January 2000 to January
competencies to deliver adequate dental care to the DHH 2018. The exclusion criteria included letters to the editor
population. Oral health is an important yet frequently over- and case reports; articles with no clear numeric results,
looked element of a population’s health. Thus, little is using not validated indices or instruments, sample sizes
known about the DHH oral health. In addition to the com- less than 10 subjects, and combining results of the DHH
munication barriers experienced by the DHH, dentists simi- population with other groups.
larly experience barriers to giving proper oral health care to
this population. However, until now there no reviews have Data Characterisation and Summary
been available up to now which summarise the relevant is- For all articles, the following variables were recorded in an
sues on oral health and dental care in DHH. Excel spreadsheet: title, authors, country, year, type (quali-
The aim of this scoping review is to compile the litera- tative/quantitative), methodological design, and compari-
ture about oral health and dental care of the DHH popula- sons with other populations.
tion. For quantitative articles, the numeric data from indices
or instruments used were gathered and summarised in ta-
bles and text. For qualitative articles, main topics and find-
MATERIALS AND METHODOLOGY ings were summarised in the text.

Research Question and Strategy

The guiding question of this scoping review was ‘What are RESULTS
the main findings reported in the literature about oral health
and dental care of the DHH population?’ A DHH population Characterisation of the Studies
was defined as those with hearing loss, either self-reported A total of 51 articles were selected for analysis. Nineteen
or objectively assessed by an audiometry instrument, in the articles were published before and 32 were published after
primary articles included for this scoping review. 2009; 15 were published in 2014 and 2015. The country of
The search query included the following keywords: hear- origin for most of the articles was India (17), followed by
ing impairment, deafness, deaf, hearing loss, people with Brazil (6), Thailand (3), Romania (3), Nigeria (3), and Saudi
disabilities, people with hearing impairment, oral health, Arabia (3). Three articles used qualitative methodology, and
dental care for persons with disabilities, Dental Plaque the remaining 48 used a quantitative methods. Among
Index, DMF Index, Index of Orthodontic Treatment Need, quantitative articles, 6 were experimental, and the remain-
Oral Hygiene Index, Periodontal Index, dentistry, dental ing 42 were observational. Twenty studies included DHH
health of people with disabilities, caries, oral hygiene, and individuals with other disabilities; four studies included
communication, bioethics, sign language, malocclusion, DHH and people without disabilities; and three included
Deaf culture, Deaf community. The search query was DHH, as well as people with other disabilities and those
adapted in an algorithm according to the requirements of without disabilities.
each database.
As the literature used a range of criteria to categorise Preventive Dental Health
the DHH population, this situation was compensated by ex- Multiple studies reported low rates of toothbrushing twice
cluding articles regarding presbycusis (hearing loss asoci- per day among DHH children and adolescents, ranging from
ated to aging) or with older DHH populations. However, 6%-14.7%.60,67,72 In China and Thailand, the rate of good
most of the articles did not mention or clasiffied the sever- oral hygiene among DHH was much lower than among non-
ity/aetiology of the hearing loss, and the majority were chil- DHH peers (e.g. toothbrushing 2x/day 15.3% vs 37.7%,101
dren, giving more homogeonity to the studies. and 86% vs 97%98). There appeared to be significant
A secondary search step included a ‘snowball’ technique knowledge differences between non-DHH and DHH students
to increase the number of relevant articles. For all articles on awareness of how to brush their teeth properly, with a
found in the databases above, their literature citations were prevalence of 79.1% and 55%, respectively.101
searched to find any other relevant articles that were not On the other hand, Suhani et al,89 using the WHO indi-
initially included. This process was repeated once more for ces, reported a higher prevalence of deleterious oral habits,
articles included in the secondary step. such as thumbsucking, mouth breathing, tongue thrust

418 Oral Health & Preventive Dentistry

 Campos et al

Table 1 DMFT, dmft and caries prevalence in DHH population

Country, year, Age DMFT dmft Caries

reference N (years) D M F (SD) d m f (SD) prevalence
Venezuela, 200344 50 3–17 1.44 0.14 0.48 2.06 1.82 0.38 0.52 2.72 92%

Saudi Arabia, 20043 23 6–7 0.87 0 0 0.87 (1.25) 7.09 0.05 0.22 7.35 (3.82) 95.7%
† 57 11–12 4.79 0.25 0.08 5.12 (3.45) 1.9 0.18 0.03 2.11 (2.53) 93%
18 5–8 0.5 0 0 (0) 0.50 (0.79) N/A N/A N/A 2.17 (1.98) N/A
37 9–12 1.81 0.02 0.02 1.76 (1.74) N/A N/A N/A 1.59 (2.03) 93.33%
India, 200839
43 13–17 2.67 0.12 0.16 2.95 (2.0) N/A N/A N/A 0.16 (0.61) 87.4%
29 18–22 3.48 0.62 0.38 4.48 (2.43) N/A N/A N/A 0.00 (0.00) N/A
India, 201474 195 6–20 1.64 0.14 0.02 1.80 (1.26) 0.33 N/A N/A 0.33 (0.24) N/A
India, 201338† 297 4–23 1.68 0.20 0.09 1.97 (1.93) 0.23 N/A 0.02 0.26 (0.85) N/A
Iran, 20071† 462 5–16 N/A N/A N/A 5.69 N/A N/A N/A 0.23 66%
Brazil, 201055‡ 50 3–12 N/A N/A N/A N/A N/A N/A N/A N/A 46%
Thailand, 201498‡ 97 ≥18 1.63 0.32 1.95 3.90 (3.22) N/A N/A N/A N/A 82.5%
India, 201552† 132 3–15 0.74 0.02 0 0.76 (1.56) 0.73 0.01 0.03¥ 0.77 (1.91) N/A
88.4%*
Albania, 201433† 147 3–18 N/A N/A N/A 4.7 (3.9) N/A N/A N/A 2.8 (2.9)
65.9%**
India, 201423† 155 3–22 N/A N/A N/A 1.10 (1.58) N/A N/A N/A 0.85 (1.76) 45.8%
India, 201366† 95 7–17 1.38 0.02 0 1.4 (1.95) 0.34 0.14 0 0.47 (1.01) N/A
China, 2012101‡ 229 17–27 1.07 0.10 0.12 1.40 (1.89) N/A N/A N/A N/A 55.9%
30 3–6 N/A N/A N/A N/A 2.33 0.37 0.70 3.40 (3.87)
42.42%**
33 7–9 N/A N/A N/A N/A 1.73 1.06 0.18 2.97 (3.17)
South Africa,
13 10–12 0.15 0.08 0.00 0.23 (0.60) N/A N/A N/A N/A
201257†
8 13–15 1.12 0.63 0.00 1.75 (3.24) N/A N/A N/A N/A 18.18%*
15 ≥16 0.20 0.27 0.00 0.47 (0.92) N/A N/A N/A N/A
50 6–8 1.4 0.04 0.16 1.6 (1.3) 2.5 0.1 0.1 2.8 (2.2) 66%
India, 201672 72 9–12 1.9 0.08 0.01 1.9 (1.2) 1.7 0.4 0.04 2.1 (1.5) 79.2%
58 13–16 2.0 0.16 0.05 2.2 (1.2) 0.5 0.6 0.07 1.1 (1.3) 46.6%
India, 200510 280 6–18 N/A N/A N/A 1.64 N/A N/A N/A N/A 93.9%
India, 201480† 200 5–16 N/A N/A N/A 2.1 N/A N/A N/A 1.3 69%
India, 201065 137 7–18 2.46 1.20 0.00 2.53 (1.72) N/A N/A N/A N/A 35.32%
India, 201112† 264 5–16 N/A N/A N/A 3.18 N/A N/A N/A N/A 72.43%
85%**
Malaysia, 201563 63 6–14 2.7 0.15 2.1 4.9 (3.28) 5.6 N/A 0.4 6.1 (4.14)
88%*
Yemen, 20152† 92 6–14 N/A N/A N/A 1.91 (2.07) N/A N/A N/A 4.37 (3.11) N/A
88.3%**
Kuwait, 200083† 312 3–29 N/A N/A N/A 5.0 N/A N/A N/A 5.3
83.6%*
* permanent dentition; ** deciduous dentition; † comparative study with other disabilities; ‡ comparative study with non-deaf population;
¥ filled, with caries

(53.3% vs 40.6%), as well as malocclusion (79.3% vs 57%) has been found that a chlorhexidine gel containing aspar-
among DHH children compared to hearing children. Avasthi tame or saccharin reduced the count of Streptococcus mu-
et al12 found a 59.78% prevalence of malocclusion signs, tans in the deaf population.29
such as the presence of spacing, crowding, crossbite, in-
creased overjet or others in DHH children. DHH Oral Disease Burden
Oral health educational interventions have demonstrated Caries prevalence in the DHH population varied widely be-
good results reducing gingival indices,11,62 bleeding,11 and tween 18.18% and 95.7%, as shown on Table 1. Only three
plaque indices7,11,62 among DHH students. Furthermore, it studies have made comparisons with non-DHH population.

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Campos et al

Chinese DHH adolescents have a caries prevalence of of DHH children22 reported communication barriers and/or
55.9% and a DMFT index of 1.40 ± 1.89 vs 13.8% and breakdowns during their dental care. Furthermore, accord-
1.36 ± 1.72 in their non-DHH peers, respectively.101 In Bra- ing to the findings of Rocha et al,70 only 22.3% of DHH
zil, DHH children have a caries prevalence of 46%, com- people perceived good communication with the dentist.
pared to 31% in non-DHH children.42 Also, in Thailand the The most commonly mentioned concerns when receiving
prevalence of caries was 53.6% with a DMFT of dental care were: communication with the dentist (52.4% in
4.83 ± 4.39 and 50.6% and 3.90 ± 3.22 among DHH stu- a survey of parents of DHH children22 and 76%in a survey
dents and non-DHH, respectively.98 of adult DHH patients71), communication with the dental
Additionally, from 65.3%3 to 79.5%39 of DHH needed assistant (41.7%22 and 61.8%71), being called from the
single-surface restorations; according to Ajami et al,1 Mehta waiting room (38.1%22 and 68.1%71), understanding what
et al53 and Nqcobo et al,58 100% of DHH subjects required will take place during the appointment (46.4%22 and
dental treatment. Oredgduba et al59 and Reddy et al66 re- 57.84%71), not pulling the face mask down to allow the
ported that from 88% to 100% of DHH subjects have never DHH patient to lipread (32.9%22and 62%71) and the pres-
visited a dentist nor received dental care. According to ence of background noise (36.5%22 and 55%71). 100% re-
Champion and Holt,22 82 of 84 DHH children have visited a ported that dentists did not understand sign language.32
dentist, of whom 45 received dental care and 38 did not. In Such difficulties increased significantly with increased hear-
Thailand, 97.5% DHH had not received preventive dental ing loss severity.71
care vs 84.2% of their non-DHH peers.98 Regarding dental anxiety, Suhani et al88 found that
Periodontal status and oral hygiene were evaluated using 59.7% of DHH people have moderate to extreme dental
several indices across the studies included, as shown in anxiety, and 5.3% have dental phobia, which is statistically
Table 2. significantly more prevalent in people with previous negative
From 59.7% to 75% of DHH showed Angle class I occlu- experiences with dentists (48.4 ± 15.14 and 36.6 ± 17.8,
sion,1,25,59 class II was found in 13% to 26%,25,29,59 and respectively) (p < 0.001).
class III comprised between 8% and 10.8% in the DHH pop-
ulation.1,25,59 Dentists’ Perceptions of DHH Dental Care
Using the Dental Aesthetics Index (DAI), it was reported In two studies, most dentists experienced difficulties com-
that 77.1% of the DHH population have normal occlusion or municating with their DHH patients (97.5%90 and 56.2%70).
slight malocclusion.96 According to the WHO indices, between Moreover, 68% of the dentists interviewed did not feel qual-
50.6%96 and 44.5%31 DHH subjects have normal occlusion, ified to work with DHH patients.90 Dentists used a variety of
and 31.5%31 to 33.8%78 showed a slight malocclusion. communication methods with their DHH patients; 90.75%
Using the Index of Orthodontic Treatment Need (IOTN), of dentists combined different methods, such as lipreading,
the Dental Health component did not differ statistically sig- writing, or sign language interpreters.73 According to Garbin
nificantly between deaf and non-deaf teenagers (30% vs et al,33 all of the dentists who cared for DHH individuals
22.4%).5,6 However, for the aesthetic component, the differ- reported that family members or friends, not professional
ence was statistically significant (43% vs 39.4%).5 interpreters, functioned as their interpreters. The majority of
dentists interviewed (60%) idenitfied costs as a reason for
DHH Barriers to Dental Care not hiring professional interpreters,90 and according to
Qualitative studies found that DHH people rarely, if ever, can Rocha et al,70 97.8% of the dentists reported the lack of an
communicated effectively with their dentists.20,30 This dem- interpreter in their Family Health Care Units.
onstrates the need for communication provisions, including Regarding dental care, 69.7% of the dentists said that
interpreters during healthcare encounters.21,30 Furthermore, dental appointments with DHH patients required more time,
parents of DHH children report always being the interpreter while 34.5% felt that equitable dental care for DHH was not
during dental sessions, even as the children age.22 This can feasible.90 More worrying was the fact that one study dem-
compromise the children’s right to privacy. Parents of DHH onstrated that 16% of dentists refused dental care provi-
children emphasise that dentists should be able to commu- sion to DHH patients due to their communication needs.90
nicate directly and effectively with their children.22 However, this differed among DHH children. One study in
DHH individuals report acceptable communication with Saudi Arabia found that 78% of dentists perceived that DHH
their dentist only in very simple specific situations where children were able to receive the same orthodontic treat-
complex explanations are not necessary (e.g. ‘spitting’). ment as non-DHH children.4 Finally, 86.6% of dentists be-
Furthermore, one article highlighted positive experiences lieved that DHH patients’ oral health was poorer than that
from DHH patients when they received dental care from a of the general population.90
DHH dentist who was able to effectively communicate with
them, demonstrating the importance of cultural and com-
munication competency.21 DISCUSSION
Regarding dental care, 46.15% DHH individuals self-re-
ported experiencing discrimination, mainly because of com- To the authors’ knowledge, this is the first scoping review
munication issues, although further reasons are not re- focused on DHH oral health. This study demonstrates that
ported.33 In addition, 87% of DHH71 and 61.1% of parents DHH struggle with significant oral health and dental access

420 Oral Health & Preventive Dentistry

 Campos et al

Table 2 Periodontal and oral hygiene indices in the DHH population

Country, year, N Age index Results (SD)

reference (years)
23 5–9 OHI–S Mean score 1.57 (0.73).
48 10–14 OHI–S Mean score 1.90 (0.67).
48 15–19 OHI–S Mean score 1.88 (1.02).
India, 200841
8 20–24 OHI–S Mean score 2.26 (0.94).
57 12–17 CPTIN 40% IPC0 42% IPC1 18% IPC2–4
29 18–23 CPTIN 45% IPC0 24% IPC1 31% IPC2–4
India, 200564 112 3–20 OHI–S Mean score 1.49 (0.88).
India, 201112 264 5–16 Gingival index Prevalence 9.65%
OHI–S Mean score 1.49(0.76)
Löe and Sillness Mean score 0.81(1.46)
India, 201065 137 7–18
OHI–S Mean score 0.46 (0.31)
Attachment loss 0.26 (0.15)mm
Albany, 201433 147 3–18 OHI–S Mean score 2.42.
India, 201672 180 6–16 CPTIN Mean score 1.7 (0.61)
IPC0: IPC1: IPC2: IPC3: IPC4:
India, 201338 297 4–23 IPC
24.2% 21.2% 11.1% 35.4% 8.1%
Löe and Sillness Mean score 1.66
India, 201473 372 6–16
Gingivitis Mean score 1.61
Plaque score Mean score 1.25 (0.35)
India, 20127 150 14–17 OHI–S Mean score 2.52 (1.08).
CPTIN 7.7% IPC0, 0.7% IPC1
India, 201561 315 6 to >15 Plaque index* Mean score 1.59.
Thailand, 201211 66 6–10 Löe and Sillness Mean score 0.94.
Mean score 0.284 in permant teeth, 0.335 in mixed dentition,
India, 20151 56 5–17 Plaque index
0.437in deciduous teeth.
OHI–S 67.8% good 25.0% fair 8.2% poor
Irán, 200774 462 5–17
Gingival index 51.1% good 39.6% fair 9.3% poor
23 6–7 Oral health index 17.4% good 60.9% fair 21.7% poor
Saudi Arabia, 200472
57 11–12 Oral health index 7% good 45.6% fair 47.4% poor
India, 201366 95 7–17 OHI–S Mean score 1.15 (0.72).
Bulgaria, 201528 100 5–12 OHI–S Mean score 2.21 (0.54).
India, 201552 132 3–15 Gingival bleeding Prevalence 66.6%
Gingival bleeding index Mean score 0.13
25 7–9
Calculus index Mean score 0.16.
Gingival bleeding index Mean score 0.23
51 10–12
Calculus index Mean score 0.32.
Gingival bleeding index Mean score 0.29
Tanzania, 200879 56 13–14
Calculus index Mean score 0.41
Gingival bleeding index Mean score 0.36
61 15–16
Calculus index Mean score 0.53
Gingival bleeding index Mean score 0.46
36 17–22
Calculus index Mean score 0.66
Löe and Sillness Mean score 1.19 (0.54)
Yemen, 20152 92 6–14
Gingival index Mean score 1.13 (0.60)

*Turesky-Gilmore-Glickman with Quigley–Hein modification.

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Campos et al

difficulties. The findings of this study call for a systematic associated with advantages such as access to better
examination of the dental experiences, complications, health services and more information, improved ability to
costs, quality of care, and outcomes of DHH individuals. engage in leisure activities and live in a healthy environ-
Given the cross-sectional nature of the articles included in ment.41 On the other hand, in Brazil, it was concluded that
the study, it is difficult to determine the causal factors as- speech is not sufficient to establish a link between the
sociated with poor oral health in DHH populations. DHH patient and the health professional.24 It is important
The information available on oral health status of this to point out that as most of the DHH populations included
population is limited. Although a great variability is apparent in this study are functionally illiterate because of the educa-
in the history of caries (DMFT/dmf), tooth decay (D/d) is tional and social barriers they face every day, written notes
the major contributor in all the articles cited, with the excep- and speech are not adequate for communica-
tion of Vichayarant et al,98 where the major contributor is tion.24,33,82,84,95
restorations (F/f). In addition, the findings of Reddy et al67 The lack of availability of specialised oral health person-
and Oregduba et al,60 where over 80% of the DHH popula- nel for DHH individuals in primary care is due to the absence
tion have never visited a dentist, clearly expresses the of training in their curricula, and this scenario is repeated in
need for dental treatment in this population. Regarding mal- every other health profession. It was found that health pro-
occlusions and periodontal health, there are not enough fessionals are not adequately prepared to care for DHH pa-
comparative studies with a non-DHH population to establish tients.19,24 In addition, a high proportion of health profes-
an association; in addition, general agreement of the indi- sionals do not feel qualified to meet the needs of the DHH;
ces used is lacking, which makes it difficult to make accu- they report a lower probability of providing health care to the
rate comparisons between these studies. Finally, although DHH and point out that these patients are the most complex
DHH populations largely experience poorer oral hygeine, to address due to communication barriers.40,53,70,90 This
there are successful examples in which this can be re- situation hinders the delivery of health services, putting at
versed through appropriate oral health education through risk the successful treatment of these patients.
visual methods.11,62,73 Due to the many communication barriers and existing
There are several potential factors that may contribute to oral health disparities, dentists and oral health profession-
the above disparities. First, hearing loss represents a major als should consider strategies to address these gaps. This
source of miscommunication in the health care setting.51 may include training on how to effectively communicate with
This affects a variety of health-related outcomes, especially DHH patients, establishing relationships with professional
health knowledge, behaviour, treatment adherence, and pa- interpreters, and providing accessible oral health pro-
tient satisfaction.15,27,52,86,93 grammes to increase knowledge on good oral hygeine and
Second, the DHH struggle with lower health literacy and techniques. It is necessary to understand the daily reality to
access to health information, including incidental learning which DHH patients are exposed, in order to create a health
opportunities.48 poor health literacy affects the quality of professional-patient connection, improve trust and patient
health care, including oral health,57 and may result in satisfaction, increase patients’ use of preventive health
poorer oral health outcomes for DHH individuals. Also, mul- measures and health appointment attendance, thus bene-
tiple studies demonstrated lower health knowledge among fitting their health.76 There are very few but still successful
DHH individuals on a variety of medical topics.36,50,57,63,91, programmes that have been developed for the training of
102,103It not known whether this is the same for oral health medical, dental and pharmacy students in treating DHH pa-
knowledge among DHH individuals. tients, resulting in professionals with better attitudes to-
Third, DHH individuals are more likely to be poorer and wards the DHH. Yet these programmes have not been es-
require public assistance, including public dental insurance. tablished as a mandatory part of the curricula.41,44,45-47,
Blanchfield et al17 analysed data from multiple national 69,40,75,76,92,97
datasets (NHIS, NHANES, NHISD) and found that DHH indi- A promising effort in Chile, through the funding from the
viduals were significantly more likely to be publicly insured, National Disability Service, has developed approaches
unemployed, and have lower family incomes. Lower socio- aimed at eliminating the communication issues DHH experi-
economic status has been shown to be a strong driver of ence in dental care, involving the joint work of dentists,
decreased access to dental health care.35 deaf people and Chilean sign language interpreters using
DHH people communicate via sign language, speech, mobile software that gives relevant information about den-
lipreading or a combination thereof. Regardless the com- tal care. This facilitates diagnosis and treatment, and im-
munication method, many of the above articles point out proves the oral health care experience of the deaf patient
the importance of good health care provider awareness on through pre-recorded sign language videos.18 Other efforts
how to effectively communicate with DHH patients in clin- around the globe have proved successful in addressing
ical settings.55 Specifically, for patients with limited English DHH health inequities. For example, the establishment of
proficiency, the use of professional language interpreters in specialised primary health-care centres, although scarce,
the UK is correlated with improved clinical care, and DHH has been well received by DHH patients, since they aim to
report positive experiences in health care encounters when eliminate the communication, health education and access
experienced professional sign language is offered. Also, in barriers previously described. In Scotland, the ‘Sensory
New Zealand, DHH access to professional interpreters is Support Centre WISC’ has a high level of health profes-

422 Oral Health & Preventive Dentistry

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