Pioneering Strategies for Relieving Dental Anxiety in Hearing Impaired Children: a Randomized Controlled Clinical Study

Abstract

Statement of the Problem: Hearing impaired children have a problem in understanding and comprehending with dental treatments. Visual language is the sensible answer of how to improve communication with them.
Purpose: To evaluate the applicability of dental sign language in Hearing impaired children in relieving anxiety during stressful dental treatment by improving their means of communication.
Materials and Method: This randomized clinical trial was carried out in the Department of Pedodontics and Preventive Dentistry which included 40 Hearing Impaired children meeting inclusion criteria. The selected children were randomly divided into the study and control group comprising of 20 each. In the control group, initial oral examination and dental treatment (oral prophylaxis and class I restoration) were performed without the use of dental sign language. In the study group, the dental sign language specific to dental treatment was educated and during their subsequent visit to the dental clinic after dental sign language reinforcement, oral prophylaxis and class I restoration were done. Subjective and objective measurements of anxiety were recorded for both groups using facial image scale (FIS), pulse oximeter and electronic blood pressure apparatus to compare for correlation. The obtained data were subjected to statistical analysis using unpaired t-test.
Results: There was a statistically significant reduction in the anxiety levels (p< 0.05) in the study group compared to the control group.
Conclusion: Dental sign language was effective in reducing the level of anxiety in children who are hard of hearing. Dental sign language was able to improve behavior positively during dental treatment and may also aid in developing a positive dental attitude among children who are hard of hearing.

Full text

Chandrasekhar S., et al. J Dent Shiraz Univ Med Sci., 2017 June; 18(2): 112-117.
112
Original Article
Pioneering Strategies for Relieving Dental Anxiety in Hearing Impaired
Children: a Randomized Controlled Clinical Study
Shalini Chandrasekhar 1, Ghanashyam Prasad Madu 2, Naga Radhakrishna Ambati 3, Pavani Reddy Suravarapu 4, Kalyani
Uppu 4, Deepthi Bolla 4
1 Senior Lecturer, Dept of Pedodontics and Preventive Dentistry, Care Dental College and Hospital, Guntur, Andhra Pradesh, India.
2 Professor and HOD, Dept. of Pedodontics and Preventive Dentistry St.Joseph Dental College, India.
3 Reader Dept. of Pedodontics and Preventive Dentistry St. Joseph Dental College, India.
4 Postgraduate Student, Dept. of Pedodontics and Preventive Dentistry, St. Joseph Dental College, India.
KEY WORDS
Dental sign language;
Anxiety;
Hearing impairment;
Dental treatment;
Received April 2016;
Received in revised form October 2016;
Accepted December 2016;
ABSTRACT
Statement of the Problem: Hearing impaired children have a problem in under-
standing and comprehending with dental treatments. Visual language is the sensible
answer of how to improve communication with them.
Purpose: To evaluate the applicability of dental sign language in Hearing impaired
children in relieving anxiety during stressful dental treatment by improving their
means of communication.
Materials and Method: This randomized clinical trial was carried out in the De-
partment of Pedodontics and Preventive Dentistry which included 40 Hearing Im-
paired children meeting inclusion criteria. The selected children were randomly
divided into the study and control group comprising of 20 each. In the control
group, initial oral examination and dental treatment (oral prophylaxis and class I
restoration) were performed without the use of dental sign language. In the study
group, the dental sign language specific to dental treatment was educated and dur-
ing their subsequent visit to the dental clinic after dental sign language
reinforcement, oral prophylaxis and class I restoration were done. Subjective and
objective measurements of anxiety were recorded for both groups using facial im-
age scale (FIS), pulse oximeter and electronic blood pressure apparatus to compare
for correlation. The obtained data were subjected to statistical analysis using un-
paired t-test.
Results: There was a statistically significant reduction in the anxiety levels (p<
0.05) in the study group compared to the control group.
Conclusion: Dental sign language was effective in reducing the level of anxiety in
children who are hard of hearing. Dental sign language was able to improve behav-
ior positively during dental treatment and may also aid in developing a positive
dental attitude among children who are hard of hearing.
Corresponding Author: Naga Radha Krishna. A. Dept. of Pedodontics and Preventive Dentistry
St.Joseph Dental College, Eluru, AndhraPradesh, India. Email: radhakrishna_27@yahoo.com
Cite this article as: Chandrasekhar S., Prasad MG., Radhakrishna AN., Suravarapu PR., Uppu K., Bolla D. Pioneering Strategies for Relieving Dental Anxiety in Hearing Impaired
Children- a Randomized Controlled Clinical Study. J Dent Shiraz Univ Med Sci., 2017 June; 18(2): 112-117.
Introduction
Deafness is known as the invisible disability. [1] Loss of
hearing can cause people to become isolated and lonely,
exerting a tremendous effect on both their social and
working life. [2] Communication is the biggest barrier
deaf children face as it is a two-way process. Patients
with hearing loss need to be helped to understand as
well as possible and also need to know how to com-
municate in the best way. [1]
Many methods of communication are available to

Pioneering Strategies for Relieving Dental Anxiety in Hearing Impaired Children- a Randomized … Chandrasekhar S., et al.
113
help the hearing-impaired children to function in a nor-
mal way (hearing aids, cochlear implants, video
phone/relay, phone relay, interpreters). However, most
of the techniques are either expensive or not readily
available, few are not useful because of the severity of
hearing impairment, and others are practical difficulties
during treatment. Sign language is the sensible answer
for improving communication with hearing impaired
children. [2]
Dental anxiety is a common problem that affects
people belonging to all ages and appears to develop
mostly in childhood and adolescence. Dental anxiety
can prevent patients from cooperating totally during
dental treatment. Dentists need to understand the anxie-
ty and its repercussions in dental care so that a relation-
ship of trust may be established with the patient for the
implementation of strategies aimed at reducing the anx-
iety caused by dental treatment. [3] Anxiety reducing
strategies are further compromised in hearing impaired
children because of their problem in communicating
with others. Hence, the aim of this study was to evaluate
the applicability of dental sign language in hearing im-
paired children for relieving anxiety during dental
treatment by improving their means of communication.
Materials and Method
This study was performed in the Pediatric and Preven-
tive Dentistry Department, St. Joseph Dental College,
India. This randomized clinical trial comprised of 40
children who were equally divided into the study and
control group. Both groups had an equal distribution of
males and females. Children who had moderate to se-
vere hearing impairment with moderate to poor oral
health requiring restoration for a class I dental lesion
and with no previous dental experience were selected
for the study. The selected children age ranged between
6-12 years with mean age of 8.4±3.4 years. The protocol
of the study was approved and ethical clearance was
taken from the Institutional Ethical Committee. In-
formed written consent was obtained from par-
ents/guardians of the selected children participating in
the study.
In the control group, oral prophylaxis and class I
restorations were done without the explanation of the
treatment procedure. During treatment, there were no
means of communication used between the operating d-
entist and the child.
In the study group, 20 children were divided into
groups of 10 each, for convenience to effectively edu-
cate dental sign language. The dental sign language
specific to dental treatment was educated by trained
professionals using visual aids. (Figure 1, 2) During
their visit to the dental clinic, a quick review of dental
sign language using the visual aids was given before the
treatment, which acted as reinforcement. All treatment
procedures and instructions to be followed were ex-
plained using the dental sign language by the operating
dentist. During the procedure, use of dental sign lan-
guage was repeated for giving instructions and also for
reassurance to patients, which acted as a means of
communication.
Figure 1: Dentisign. [12]
Subjective and objective measurements of anxiety
were recorded in both groups using electronic blood
pressure apparatus (Figure 3a), physiological parameters
inclusive of the pulse oximeter (Figure 3b) and Facial
image scale (FIS) [4] (Figure 3c). Data obtained were
analyzed using statistical software (SPSS version 15.0,
SPSS Inc, Chicago, USA). The unpaired t-test was used
to calculate the correlation between the subjective and
objective measurements of anxiety between boys and g-

Chandrasekhar S., et al. J Dent Shiraz Univ Med Sci., 2017 June; 18(2): 112-117.
114
Figure 2: Additional dental signs used in the study. [13]
irls in both study and control group. The unpaired t-test
was used to calculate the correlation between the varia-
bles before, during and after treatment between the
study and control groups.
Results
The mean values and standard deviation of systolic and
diastolic blood pressure, FIS and pulse rate among girls
and boys in the control group are presented in Table 1.
The mean systolic blood pressure in girls and boys were
114.5±1.9 and 114.51±1.7 respectively. The mean dias-
tolic blood pressure in girls was 71.96±1.4 whereas in
boys it was 67.33±1.04. The FIS values in girls and
boys were 3.42±0.11 and 2.81±0.16 respectively. The
pulse rate in girls was 99.66±3.8 and for boys it was
91.66±1.41. There was no statistically significant differ-
ence in subjective and objective measurement of anxiety
in the control group. (Table 1)
The mean values and standard deviation of systol-
ic and diastolic blood pressure, FIS and pulse rate
among girls and boys in the study group are presented in
Table 2. The mean systolic blood pressure in girls and
boys were 121.09±2.19 and 120.51±1.69 respectively.
The mean diastolic blood pressure in girls was
73.73±1.13 whereas in boys was 72.92±0.94. The FIS
values in girls and boys were 2.04±0.26 and 1.56±0.16
respectively. The pulse rate in girls was 91.76±2.57 and
for boys it was 89.05± 2.02. There was statistically sig-
nificant difference in subjective and objective measure-
ment of anxiety (p< 0.05) except for the pulse rate in the
study group. (Table 2)
The mean values of systolic and diastolic blood
pressure, FIS and pulse rate among children in the study
and control group before, during and after dental treat-
ment are presented in Table 3.
Before the initiation of dental treatment, there was
a statistically significant difference in systolic and dias-
tolic blood pressure among study and control group
with higher values in the control group. During and after
the completion of dental treatment there was no statisti-
cally significant difference in systolic and diastolic
blood pressure among the study and the control group
(Table 3).
With respect to FIS and pulse rate in children,
there was no statistically significant difference in the
study and control group before the initiation of dental tr-
Figure 3: Subjective and objective measurements of anxiety, a: Electronic blood pressure apparatus, b: Pulse oximeter, c: Facial image
scale (FIS). [4]

Pioneering Strategies for Relieving Dental Anxiety in Hearing Impaired Children- a Randomized … Chandrasekhar S., et al.
115
Table 1: Mean values and standard deviation of systolic and diastolic blood pressure, Facial image Scale (FIS) and pulse rate among
girls and boys in the control group.
Control group
Systolic blood pressure
Diastolic blood pressure
FIS
Pulse rate
Girls
114.5±1.9
72.18±1.4
3.42±0.11
99.66±3.8
Boys
114.51±1.7
67.33±1.04
2.81±0.16
91.66±1.41
p-value
0.7
2.4
3.8
0.89
eatment. During and after the completion of dental
treatment there was a statistically significant difference
in FIS values and pulse rate among study and control
group with higher values in the control group (Table 3).
By using the dental sign language, there was a
significant reduction in anxiety levels as described by
the parameters from the pre-treatment to post-treatment
period in the study group. However, in the control
group, there was no significant difference in the anxiety
levels from the pre-treatment to the post-treatment peri-
od (Table 3). Dental sign language has proved to be
effective in reducing the level of anxiety in children
who are hard of hearing.
Discussion
Deaf people have a problem in learning health recom-
mendations. Limited knowledge of deaf people makes
their health care more complicated, due to their com-
munication problems. [5]
The hearing-impaired children may have special
accessibility problems in health care because the health
system does not meet their special needs for communi-
cation. Healthcare staffs are often not aware of the bar-
riers faced by the hearing impaired. Many hearing-
impaired patients complain that they were not properly
informed about the disease they had, treatment and
prognosis. Hearing-impaired patients have the same
rights to full information as other patients. Inadequate
communication may create problems for the profession-
al if the patient does not follow treatment instructions
properly. [6]
Communication is the process of exchanging mes-
sages or information between two or more parties. The
basic forms of communication are of two types such as
verbal and non-verbal communication. [7] There has
been little consideration of dental care for children with
hearing impairments. Till date, there are no studies re-
ported in the literature comparing the efficacy of sign
language described specifically for dentistry in relieving
anxiety for hearing impaired children.
Dental fear has been ranked fourth among com-
mon fears. Anxious individuals are generally uncooper-
ative during their dental visits, tend to cancel more den-
tal appointments, and develop decreased pain threshold.
[8] The main causes of dental fear and anxiety reported
by the children were fear of pain and fear of unknown.
[9]
In the present study, the mean values of subjec-
tive and objective measurements of anxiety were higher
in girls compared to boys. This is similar to the observa-
tions in the studies conducted by Berge M et al. [10]
and Chellappah NK et al. [11]
Literature indicates a shortage of information on
the prevalence of dental fear in special children. This
study demonstrated that a high proportion of hearing
impaired children suffered from dental anxiety, thus
requiring measures to overcome them. Dental sign lan-
guage is a sign-language system specially designed for
dentistry, explaining the various dental equipment, pro-
cedures, and techniques. Hearing impaired children
cannot verbalize their concerns and fears during the
dental treatment. Dental sign language can help in re-
storing trust in a dentist-patient relationship. In the pre-
sent study, fear of the unknown was eliminated by ex-
plaining the procedure to children using the dental sign
language. Raymond Cadden was the creator of the
eight-sign method (Dentisign) that was designed to re-
duce the anxiety levels during dental treatment. But the-
Table 2: Mean values and standard deviation of systolic and diastolic blood pressure, Facial image scale (FIS) and pulse rate among
girls and boys in the study group.
Study group
Systolic blood pressure
Diastolic blood pressure
FIS
Pulse rate
Girls
121.51±1.69
73.73±1.13
2.04±0.26
91.76±2.57
Boys
114.59±2.19
71.18±0.94
1.56±0.16
89.05±2.02
p– Value
0.004
0.014
0.01
0.54

Chandrasekhar S., et al. J Dent Shiraz Univ Med Sci., 2017 June; 18(2): 112-117.
116
Table 3: Mean values of systolic and diastolic blood pressure, Facial image scale (FIS) and pulse rate among children in study and
control group before, during and after dental treatment.
Groups
Systolic blood pressure
Diastolic blood pressure
FIS
Pulse rate
Pre
During
Post
Pre
During
Post
Pre
During
Post
Pre
During
Post
Control
111
118.8
113
68.1
71
69.6
2.9
3.45
3.1
92.85
98.3
94.65
Study
125
110.7
117.3
75
72
71.7
2.85
1.3
1.05
96.75
87.7
85.55
p-value
<0.05*
>0.05
>0.05
<0.05*
>0.05
>0.05
>0.05
<0.05*
<0.05*
>0.05
<0.05*
<0.05*
ese 8 dental signs were not sufficient to communica-te
effectively with the disabled children. [12] Hence, in
combination with Dentisign additional signs specific to
dentistry [13] were used to explain the procedure.
In the present study, there was a statistically sig-
nificant difference in systolic and diastolic blood pres-
sure before the initiation of treatment, with higher val-
ues in the study group. Once the treatment was initiated
there was a marked reduction in the blood pressure val-
ues in the study group, which was statistically signifi-
cant.
With respect to the values of FIS and pulse rate,
there was no statistically significant difference between
the study and the control group before the initiation of
treatment. With the initiation of treatment, there was a
statistically significant difference between the study and
control groups with higher values in the control group.
Similarly, after completion of treatment, there was a
statistically significant difference between the study and
control groups with higher values in the control group.
These findings indicate that with the use of sign lan-
guage designed specifically for dental treatment a statis-
tically significant reduction in the anxiety levels was
observed in the hearing impaired children.
Champion et al. [14] evaluated difficulties experi-
enced by hearing-impaired children in accessing dental
care and/or in receiving dental treatment. Major issues
raised by respondents were lack of deaf awareness, lack
of specific calling systems, need to learn and to use
basic sign language, using explanatory videos/books,
dentist not pulling the mask down to speak to, not fac-
ing child to communicate, and lack of positive attitude
of dentist in handling hearing impaired children. [14]
In our study, most of the issues raised by the hea-
ring-impaired children respondents were overcome by
utilizing the dental sign language. Children were able to
express their thoughts and feelings with the dentist dur-
ing the procedure using the signs such as stop, suction,
pain and so on. This shows that an element of control
and also means of communication were provided for the
hearing impaired children which may explain the reason
for decreased anxiety in the study group. Children were
able to learn dental sign language within 20 minutes and
used learned signs effectively during dental treatment
which proves that the dental sign language was easy to
learn, remember and implement.
The limitation of the present study is the sample
size, further studies with a larger sample size that in-
clude more children in each gender and with different
age groups are recommended. Moreover, further studies
can be pursued by comparing sign language with other
means of communication in children having differing
levels of hearing impairment. In this study, the blood
pressure was different before the procedure which may
cause an error, but this was a variable that could not be
controlled. Since even an eye-to-eye communication
may impact the anxiety of a patient, there might be a
bias in the selection of the study group. The effective-
ness of sign language could have been further proved by
including a third control group that only receives a sim-
ple communication like holding the hands.
Conclusion
In the present study, dental sign language proved to be
effective in relieving the anxiety in hearing impaired
children. By learning these simple signs, dentists can
help in developing a positive attitude and make hearing
impaired children dental visits more pleasant.
Conflict of Interest
The authors of this manuscript certify that they have no
conflict of interest.
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