British Sign Language and its Role in Dentistry

A hearing impairment occurs when there is a problem with, or damage to, one or more parts of the ear.¹ Within the UK, 11 million people are deaf or are hard of hearing.² Approximately 400,000 people in the UK experience the dual sensory impairment of deafness and blindness.³ The level of deafness may be considered mild (less than 40 dB) to profound (more than 90 dB).⁴ Globally in 2019, it is thought that 1.57 billion people, 70 million of whom were children aged 0–15 years, had a form of hearing loss, accounting for 1 in 5 people worldwide.⁵ Worryingly, 60% of hearing loss in children is a result of preventable causes, such as infections and vaccine-preventable diseases.⁶

Hearing loss is common and negatively affects multiple aspects of an individual's life when unaddressed, or when the individual's communication needs are unsupported.⁵

Deafness may be classified based on its aetiology (i.e. genetic, congenital or acquired), its location (conductive, sensorineural, mixed or central) and onset (pre-lingual, peri-lingual, post-lingual or late onset).⁴ Conductive hearing loss occurs due to problems with the outer and middle ears, sensorineural hearing loss involves issues with the inner ear and auditory nerve, while mixed hearing loss involves both conductive and sensorineural causes. Central hearing loss occurs when the cochlea functions normally, but the issue involves other areas of the brain.¹

The effects of hearing impairments on general and dental health

Deafness can naturally have a devastating effect on an individuals' ability to communicate. An increased degree of hearing loss is associated with greater psychological, emotional, and social disturbances and the extent of the disturbance depends on age of onset, training and acceptance of the disability.⁷

Individuals with hearing impairments are more likely to have a lower socio-economic status, achieve poorer educational outcomes and higher rates of unemployment.⁸ A 2015 cross-sectional study assessed the current general health of the signing deaf community in the UK compared with the general population. The study assessed 298 deaf people, aged 20–82 years.⁹ The results highlighted higher rates of obesity in the deaf population, especially for those over the age of 65 years. Hypertension was noted in 48% of the sample, compared to 21% of the general population, and 29% of the deaf individuals were unaware of this (compared to only 6% of the general population).⁹ Adequate control of the hypertension was recorded in 42% of the deaf population, compared to 62% of the general population. The study concluded the health status of the deaf population was poorer than that of the general population, with under-diagnosis and under-treatment of chronic conditions, which was putting them at risk of preventable ill-health.⁹

Campos et al completed a scoping review of the literature specifically targeting oral health and dental care in deaf and hard of hearing (DHH) populations.⁴ The review analysed 50 articles, and the results suggested the DHH population experienced poorer oral hygiene and a higher prevalence of caries than non-DHH individuals.⁴

Individuals with hearing impairments experience significant problems in accessing health and in communicating within medical settings.⁷ A lack of sign language, deaf awareness training (DAT) and the availability of communication aids within healthcare settings has been reported.⁷

Research assessing deafness and its impact on dental health within the UK is limited. Champion and Holt completed a questionnaire-based study investigating dental care for children and young people who suffered a hearing impairment.⁷ The parents of 84 children were contacted through the National Deaf Children's Society, 98% (n=82) of the children had visited a dentist. Children with a profound hearing loss were 23% less likely to have attended before the age of 5 years compared to those who experienced less severe hearing loss.⁷ Of the families, 63% reported at least one communication problem while receiving dental care, and there was a significant association with more severe impairments.⁷ Of the 84 children, 53 experienced at least one communication issue at the dentist, these included:

• Being called from the waiting room (32%);
• Communication with the nurse (35%);
• Dentist (44%);
• Understanding what will take place (39%).⁷

The difficulties were reported more commonly for children with profound hearing loss as well. Other problems faced at the dentist included:

• The dentist always (n=27) or sometimes (n=25) wearing a mask;
• Background noise (i.e. music/traffic noise) in the surgery all the time (n=30) or sometimes (n=18).⁷

This study also investigated the communication methods used by the children in the dental practice and found that 69% of the children used oral communication or lip reading.⁷ More than 30 children used British Sign Language (BSL), just over 20 used Sign Supported English (SSE), fewer than five used cued speech, and just under 10 used another form of communication⁷. Only three of the dentists who treated the 84 children were reportedly specially trained to treat children with hearing impairments, and another three were able to use cued speech or BSL⁷.

The Champion and Holt study cited above did have some limitations, including its small sample size and its selection method, which resulted in the study population being unrepresentative because the higher proportion of patients with profound hearing loss (62%) included in the study introduced a bias to the results.⁷

However, the results of Campos et al also highlighted that the DHH population experience significant struggles with oral health, dental access and communication issues,⁴ which is supported by Champion and Holt.⁷

The lack of studies assessing dental health and the communication issues faced by the deaf community within the UK emphasizes the need to investigate this important topic further.

The inability to effectively communicate is a barrier to using healthcare services.¹⁰ Patel et al sent a freedom of information (FOI) request to the 20 UK dental hospitals to gain an insight into the number and cost of interpreter and sign language appointments.¹¹ Sixteen dental schools provided this information, and the mean number of interpreter and sign-language appointments were 11,691 (± 1565) and 77 (± 359), respectively over a 24-month period, at an average combined cost of £56,847 (range £1163–£191,647)¹¹ Unfortunately, for this article, the present authors were unable to find any literature on the use of BSL interpreters in primary care settings.

British Sign Language

Interestingly, Champion and Holt⁷ highlighted that ‘it has been suggested that all dentists should learn simple sign language and the principles of communication with those who have hearing impairments’ this being a quotation from an article published in 1976.¹² Jones and Cumberbatch¹³ reported on the introduction of mandatory teaching of sign language to undergraduate dental students at the University of the West Indies (UWI), Kingston, Jamaica. This teaching was brought into the undergraduate course to help bridge the communication gap between dentist and deaf patients.¹³ The authors reviewed over 90 Doctor of Dental Surgery and Doctor of Dental Medicine courses in North America, the UK and parts of Europe and Australia and found that no mandatory training in sign language was included in the curricula. The UWI programme, involved two sign language courses and a direct clinical competency requirement and the preliminary findings showed a positive impact on the dental care access and treatment provision for deaf patients.¹³ The authors concluded that the mandatory training of sign language had not just removed the communication barrier, but had also increased the empathetic and ethical development of the dental student as well.¹³ It is unfortunate and alarming that BSL is not routinely taught in UK dental schools.

Within the UK, 150,000 people use BSL as their preferred method of communication.² The BSL Act 2022 recognizes it as a language of England, Wales, and Scotland,¹⁴ it is a visual, spatial language using movements of the hands, body, face and head, which has its own grammar, syntax, idioms and regional variations.¹⁵ Sign language itself, is recognized in more than 30 countries.¹⁶

The remainder of this article highlights some of the basic aspects of BSL. It is important to highlight that for many individuals with a hearing impairment, English may not be their first language and their written communication skills may be less developed than the dental team expects. The ability of the professional to use BSL rather than written language would be beneficial both for the patient and the team.

The BSL alphabet

A basic tool in BSL is the alphabet, which can be used to finger spell words to individuals. Figure 1 shows the alphabet.¹⁷ It shows a right-handed individual, with the left hand being used as a ‘chalk board’ and the right hand being used the ‘chalk’. The opposite can be used for a left-handed individual. The vowels ‘A, E, I, O, U’ are represented by the left hand's thumb, index, middle, ring, and little fingers, respectively, which the right index finger identifies. The consonants are represented by different signs, some static using a combination of left and right-hands (e.g. B), some using a single hand (e.g. C), and some using both hands with a movement (e.g. H) as indicated in Figure 1.¹⁷ Finger spelling would be used if the actual signs for the word were unknown, or where one does not exist.

Figure 2 shows some BSL greeting signs for everyday use, the arrows indicate the movement needed to complete the sign. Note, the sign for ‘hello’ is the same as the sign used for ‘goodbye’ and here, naturally, the context of the conversation, and also the use of lip reading, would highlight the meaning of the sign. This is true for ‘please’ and ‘thank you’. Figure 3 shows some additional signs that may be useful in a dental setting. Often a deaf individual as well as a hearing individual who signs, may have their own sign-name. For individuals who do not have a sign to represent their name, they can simply finger spell their name (Figure 4). This would include the signs for the following ‘My, Name, What?’ followed by the finger spelling ‘DANIEL’.

Conclusion

A hearing impairment can significantly affect an individual's life in numerous ways. With 11 million individuals in the UK being affected by some form of hearing impairment, it is vital the dental professional can communicate effectively in a clinical setting. This is important when considering gaining valid consent. Hearing loss detrimentally affects general and dental health.

Within the UK, 150,000 deaf individuals use BSL as their preferred form of communication. BSL is a visual and spatial language using movements of the hands, body, face and head, and it has its own grammar, syntax, idioms and regional variations. This article has introduced the reader to the BSL alphabet, as well as to some basic signs that could be used within the clinical setting to help break the communication barrier experienced by many patients with a hearing impairment.

More research is required into the impact hearing impairments may have on dental health. Furthermore, BSL training could be incorporated into the communication skills teaching in the undergraduate programmes within the UK.