Special need care is an integral part of dentistry, and is often overlooked. This is an in-depth presentation on the dental management of one aspect of special needs children, particularly those with hearing impairment.

1. DR. LANRE-OYEBOLA
DENTAL
MANAGEMENT
OF HEARING-
IMPAIRED
INDIVIDUALS

2. OUTLINE
• Introduction
• Epidemiology
• Classification of Hearing Impairment
• Etiology
• Clinical & Oral Manifestations
• Common Dental Problems
• Hearing Impaired Individuals Management
• Conclusion
• References

3. INTRODUCTION
• Hearing is the usual way of acquiring language, which is
one of the most important attributes of man.
• Language allows human beings to communicate with each
other and has had a decisive participation in the
development of society and its many cultures.

4. INTRODUCTION
• According to WHO, It is called hearing defect and defined
as the inability to hear as well as a person whose hearing
is normal.
• Normal hearing ranges from -10 to 15dB.
• Disabling hearing loss means hearing loss greater than 40
dB (Decibel) in the ear with better hearing (in adults), and
superior to 30 dB in the ear with better hearing (in
children).

5. EPIDEMIOLOGY
• Hearing loss is one of the most common chronic health
problems, affecting people of all ages, in all segments of
the population and at all socioeconomic levels.
• More than 5% of the world's population (360 million
people) suffer from disabling hearing loss (328 million
adults and 32 million children).
• A study carried out by Adeyemi A Labaeka et al in UCH
Ibadan, showed that the burden of severe hearing
impairment is increasing with two-thirds of these hearing-
impaired people residing in developing countries.

6. EPIDEMIOLOGY
• The incidence increases with age: Approximately 314 of
every 1000 people over 65-years-old suffers hearing loss.
• Hearing loss may vary from a mild, but significant decrease
in hearing sensitivity to a total loss.

7. EPIDEMIOLOGY
• A study carried out by Oredugba et al involving 50 students
of Wesley School 1 for the Deaf, Lagos (26 males and 24
females, aged 10–19 years) reported only 12 percent of
pupils had received dental care and 94 percent brushed
their teeth once daily.
• Major reported dental problems include bleeding gums
(36%), tooth discoloration, and tooth decay with more than
90 percent willing to have a dental check-up.
• This shows the importance of hearing-impaired individuals
to have adequate dental treatment.

8. SOURCE – GOOGLE

9. CLASSIFICATION OF HEARING
IMPAIRMENT
• According to type:
• Sensorineural hearing loss, which means there is a
problem occurring in either the inner ear or the auditory
nerve, which delivers sound to the brain.
• Conductive hearing loss, which means sound is not
reaching the inner ear, usually due to an obstruction,
deformity or trauma in the outer or middle ear, such as
microtia.
• Mixed hearing loss means the hearing loss is being caused
by a combination of the two.

10. CLASSIFICATION CONTD.
• According to the age of onset:
• prelingual hearing loss
• post lingual hearing loss
• According to severity (WHO)
Impairment Audible dB level
No impairment 25 dB or less
Slight impairment 26 - 40 dB
Moderate impairment 41 -60 dB
Severe impairment 61- 80 dB
Profound impairment 81 dB or more

11. ETIOLOGY
• Genetic : usher syndrome, Cerebral palsy (more of visual but
hearing can occur), pendred syndrome
• Age: Presbycusis
• Disease: measles, mumps, rubella, adenoids, chlamydia
infection (common in children), congenital syphilis, fetal
alcohol syndrome.
• Drug induced: aminoglycoside, macrolide antibiotics,
diuretics, chemotherapeutic agents.
• Noise induced
• Trauma
• Oto-toxic chemicals: heavy metal toxicity, pesticides.

12. SOURCE – GOOGLE

13. CLINICAL MANIFESTATIONS
• Difficulty following a conversation when two or more
people are speaking at the same time or in noisy areas.
• A consistent ringing or buzzing in the ears (tinnitus)
• A feeling of being off-balance or dizzy (vertigo)
• Hearing with or without speech impairment
• Lack of social and emotional development
• Delayed or Lack of learning

14. ORAL MANIFESTATIONS
• Mouth breathing leading to xerostomia
• Increased risk for dental caries
• Increased risk for periodontal infections

15. COMMON DENTAL PROBLEMS
• One of the repercussions of this disability is that patients
will not be able to identify and communicate dental health
problems in their own mouths, and they may arrive at our
dental clinics with advanced disease.
• Some common dental problems associated with hearing
impaired individuals are:
• Abuse and Neglect
• Traumatic Dental Injury
• Poor oral hygiene.
• Dental Caries.
• Gingivitis
• Periodontal disease

16. ABUSE AND NEGLECT
• Physical abuse is shocking due to the marks it leaves, not all
signs of child abuse are as obvious.
• Ignoring a child’s needs, putting them in unsupervised,
dangerous situations, exposing them to sexual situations,
or making them feel worthless or stupid are also forms of
child abuse and neglect—and they can leave deep, lasting
scars on children.

17. ABUSE AND NEGLECT
• Regardless of the type of abuse, the result is serious
emotional harm.
• Neglect—Dental neglect is defined by the American
Academy of Pediatric Dentistry(AAPD)as failure of
caregivers to provide prerequisites of proper oral function
via seeking and timely dental treatment services necessary
to be free from pain and infection.

18. SIGNS OF CHILD ABUSE
• Be excessively withdrawn, fearful, or anxious about doing
something wrong.
• Show extremes in behavior (extremely compliant,
demanding, passive, aggressive).
• Not seem to be attached to the parent or caregiver.
• Have frequent injuries or unexplained bruises, welts, or
cuts.
• Be always watchful and “on alert,” as if waiting for
something bad to happen.
• Shy away from touch, flinch at sudden movements, or
seem afraid to go home.

19. SIGNS OF CHILD NEGLECT
• Have consistently bad hygiene (unbathed, matted and
unwashed hair, poor oral hygiene, noticeable body odor).
• Untreated pain, infection, bleeding or trauma affecting the
orofacial region.
• History of lack of care and continuity of dental treatment.
• Be frequently unsupervised or left alone or allowed to play
in unsafe situations.
• Be frequently late or missing from school.

20. TRAUMATIC DENTAL INJURY
• Dental trauma (traumatic dental injury) is an impact injury
to the teeth and/or other hard and soft tissues within and
around the vicinity of the mouth and oral. It is common
amongst special needs children.
• Hearing impaired individuals are more prone to TDIs due to
the feeling of being off-balance or dizzy (vertigo). Hence,
therefore proper preventive approaches should be taking
into consideration.
• Physical abuse often also presents as oral trauma, hence
check for signs of abuse and neglect.

21. POOR ORAL HYGIENE
• Special needs children may be at higher risk for abuse or
neglect than children without disabilities.
• Research shows severe neglect disrupts young children's
cognitive and executive functions, Without intervention,
these disruptions can lead to learning problems, social
adjustment difficulties, mental health problems, and
physical disease and other challenges.

22. POOR ORAL HYGIENE
• Hearing Impaired Individuals with neglect are more prone
to poor oral hygiene.
• Hearing Impaired children require adequate monitoring and
supervision when taking care of their oral hygiene.
• Also Hearing Impaired individuals have delay learning
ability. Therefore they require patience when educating
them on good oral hygiene practices.
• Poor Oral hygiene can lead to a sequalae of oral diseases.

23. DENTAL CARIES
• Dental Caries has been found to be of high prevalence in
individuals with special needs (Oredugba et al), poor oral
hygiene is a major contributory factor. Others include
mouth breathing which causes Xerostomia.

24. GINGIVITIS
• This is caused by poor oral hygiene therefore good oral
hygiene practices must be enforced as an important and
major way to prevent this disease.

25. PERIODONTAL DISEASE
• The development of periodontal disease is initially given by
the presence of dental plaque, but there are factors that
increase risk such as immunologic, hormonal and cellular
that can lead to a faster or aggressive evolution.
• This happens due to poor oral hygiene leading to
accumulation of plaque and calculus.
• Good oral hygiene practices to be enforced.

26. HEARING IMPAIRED
MANAGEMENT
• The whole dental team which includes clinical and non
clinical staff should undergo some training with respect to
hearing impaired individuals.
• These training will inform
• Patient’s comfortableness
• Communication
• Empathy
• Patience

27. COMMUNICATION METHODS
• Hand signs
• Facial expressions
• Lip reading: remove face mask or use transparent
face mask.
• Writing: If writing use a full sheet of paper on a
clipboard and write legibly.
• Use of Picture Exchange Communication System
(PECS).
• Video instructional materials.

28. SOURCE – GOOGLE
A transparent mask, worn by an health care professional, which allows
hearing impaired individuals to be able to lip read.
Dental sign language for hearing impaired
individuals

29. SOURCE – GOOGLE

30. SOURCE – GOOGLE
A PECS chart with figures of dental treatment to be done in sequence.
A PECS chart with figures depicting step vice teeth brushing.

31. SOURCE – GOOGLE

32. SOURCE – GOOGLE

33. PRE-VISITS
• The caregiver’s and patient’s initial contact with the
dental practice allows both parties an opportunity to
address the child’s primary oral health needs and to
confirm the appropriateness of scheduling an
appointment with that particular practitioner.
• use of pre-visit Imagery, age appropriate videos.
• video instructional materials
• Caution caregivers not to instill fear
• Oral health education

34. HOME DENTAL-CARE
• Dental education of parents, guardians, caregivers is
important to ensure children with Hearing loss do not
jeopardize their overall health by neglecting their oral
health.
• The parents (or guardians) are initially responsible for
establishing good oral hygiene in the home.
• Home dental care for these children should begin in
infancy

35. HOME DENTAL-CARE
• For older children who are unwilling or physically unable
to cooperate, the dentist should teach the parent or
guardian correct tooth brushing techniques that safely
restrain the child when necessary.
• Most common technique recommended is horizontal
scrub method as it is easy to perform and understand.

36. HEARING IMPAIRED
MANAGEMENT
• Access to the oral cavity can be difficult for many reasons.
• The acclimation and use of behavioural techniques can be
useful to develop a good relationship and trust in order to
achieve cooperation.

37. HEARING IMPAIRED
MANAGEMENT
• The clinical characteristics of their oral cavity do not differ
greatly from the rest of the individuals.
• Hard tissue alterations may include a higher prevalence of
enamel hypoplasia and dental demineralization related to
prematurity and rubella, which are two common causes of
deafness.
• The dental wear (bruxism) is common and this habit
appears during periods of inactivity and can serve to fill the
sensory void left by the disability.

38. HEARING IMPAIRED
MANAGEMENT
• Dental management considerations depends on:
• Age of onset
• Degree of hearing impairment
• Presence of other handicapping conditions
• Degree of dependence
• Patient’s attitude and behaviour
• Parental attitude and behaviour given the situation.
• Previous dental treatment and acceptance.

39. SPECIAL CONSIDERSTIONS
• Behavioral
• Ask child and parent how they usually communicate (sign
language, lip reading, hearing aid, note writing, or
combination).
• Periodically confirm that you are understood throughout the
appointment.
• Make visits as short as possible.

40. SPECIAL CONSIDERSTIONS
• Lip readers:
• Face the patient while speaking, speak clearly and naturally,
and make sure that your mask is removed while speaking
and mouth is visible. It is preferable to be at the same level
as the child.
• Gain the child’s attention with a light touch or signal before
beginning to speak.
• Communicate only when the patient is looking at you.
• Speak naturally, neither very quickly nor very slowly. Use of
complete sentences is preferred over the use of single word
directives.

41. SPECIAL CONSIDERSTIONS
• Avoid technical terms.
• Excessive chat-lip reading is tiring.
• Sign language:
• Look directly at the child and not the interpreter when
talking.
• Speak slowly and clearly to the child—not in the third
person about the patient.
• Facial expressions and gestures may be very helpful.

42. SPECIAL CONSIDERSTIONS
• Hearing aids:
• Eliminate or minimize background noise (music, etc) during
the conversation.
• Avoid sudden noises and putting your hands close to the
hearing aid during treatment to avoid buzzing.
• The child may want to adjust or turn off the hearing aid
during treatment; inform them [show] before you start to
use dental equipment.

43. HEARING IMPAIRED
MANAGEMENT
• The reception staff should introduce themselves to the
patient and offer to lead the patient to the clinic or waiting
area and determine the level of assistance the patient
needs.
• Make the patient feel comfortable.
• Determine the degree of hearing impairment.(By referring
to an ENT specialist if caregiver/interpreter doesn’t know)
• Find out if companion is an interpreter/caregiver and
explain every procedure and instructions to them so they
can reinforce and monitor them at home.
• Establish rapport
• Introduce other office personnel very informally.

44. HISTORY TAKING
• Take a complete medical history.
• Management is multidisciplinary. This will enable
you know other medical problems and a referral
should be sent to patients physician when
necessary.
• Presenting complaints
• History of presenting complaints
• Past dental history
• Past medical history including immunization history.
• Past surgical history
• Family history
• Social history

45. EXAMINATION
• Remain within the child’s visual field during Examination.
• Make physical contact reassuring and do not grab or move
patient without prior notice.
• Allow patients to ask questions about the course of
treatment and answer them. (it can be through writing)
• Allow a patient who wears hearing aids to keep them on
except patient requests to take them off.

46. EXAMINATION
• Use the Tell-Show-Do approach (Show-say-do), especially
when using vibrating equipment-hearing impaired children
may be particularly afraid of the unknown. Watch the
patient’s expression. Make sure the child understands what
the dental equipment is and what is going to happen
• Describe in detail instruments and objects to be placed in
patient’s mouth.
• Use Video recordings, large texts and dental pamphlets.

47. EXAMINATION
• A comprehensive clinical examination includes;
• evaluation of the head, neck, and oral structures
• Look for signs of physical abuse during the examination.
Note findings in chart and report any suspected abuse to
Child Protective Services, as required by law. Abuse is more
common in children with developmental disabilities and
often manifests in oral trauma.
• caries- and periodontal risk assessment.
• Caries-risk assessment provides a means of classifying
caries risk at a point in time and, therefore, should be
applied periodically to assess changes in an individual’s risk
status. -assessments of occlusion, habits.

48. INVESTIGATIONS
• all available adjunctive diagnostic aids such as radiographs,
photographs, or blood tests should be utilized where
indicated

49. MEDICAL CONSULTATION
• The Paediatric dentist should coordinate care via
consultation with the patient’s other care providers.
• When appropriate, the physician should be consulted
regarding medications, sedation, general anesthesia, and
special restrictions or preparations that may be required to
ensure the safe delivery of oral health care.
• A multidisciplinary approach may be necessary in complex
case management.
• The paediatric dentist and staff always should be prepared
to manage a medical emergency.

50. INFORMED CONSENT
• All patients with hearing impairment must be able to
provide informed consent/assent for dental treatment and
have someone present who legally can provide this service
for them.
• Informed consent should be well documented in the dental
record through a signed and witnessed form.

51. ANXIETY ASSESSMENT
• Persons with hearing impairment may express a greater
level of anxiety about dental care than those without a
disability, which may adversely impact the frequency of
dental visits and, subsequently, oral health.
• An assessment of anxiety or dental fear is challenging in this
population and, in some cases, an estimation through
parent or caregiver report is helpful.

52. BEHAVIOURAL GUIDANCE
• Behavior guidance can be challenging and communication
may be limited due to anxiety and the impaired hearing.
Because of dental anxiety, a lack of understanding of dental
care, oral aversion, or fatigue from multiple medical visits
and procedures, children with hearing impairment may
exhibit resistant behaviours. These behaviors can interfere
with the safe delivery of dental treatment.
• With the caregiver’s assistance, most patients can receive
oral health care in the dental office.

53. BEHAVIOURAL GUIDANCE
• Protective stabilization can be helpful for some patients
(e.g., those with aggressive, uncontrolled, or impulsive
behaviors; when traditional behavior guidance techniques
are not adequate) safe delivery of care and with consent.
• When non-pharmacologic behavior guidance techniques
are ineffective, the practitioner may recommend sedation
or general anesthesia to allow completion of
comprehensive treatment in a safe and efficient manner.

54. PREVENTIVE STRATEGIES
• Individuals with Hearing impairment may be at increased
risk for oral diseases which further jeopardizes their overall
health.
• Education of parents/caregivers is critical for ensuring
appropriate and regular supervision of daily oral hygiene.
• The team of dental professionals should develop an
individualized oral hygiene program that accommodates the
unique disability of the patient. Assistance from other
health professions may be beneficial.

55. PREVENTIVE STRATEGIES
• Brushing with a fluoridated dentifrice twice daily helps
prevent caries and gingivitis.
• Electric toothbrushes and floss holders may improve
compliance.
• Paediatric dentists should encourage a non-cariogenic diet
for long term prevention of dental disease.
• Medications and their oral side effects should be routinely
reviewed as these can have an impact on caries and
periodontal risk.

56. PREVENTIVE STRATEGIES
• Patients with hearing impairment may benefit from sealants
which reduce the risk of caries in susceptible pits and
fissures of primary and permanent teeth.
• Topical fluorides (e.g., sodium fluoride, silver diamine
fluoride)may be indicated when caries risk is increased.
• Interim therapeutic restoration (ITR) using materials such as
glass ionomers that release fluoride, may also be useful as
both preventive and therapeutic approaches.

57. PREVENTIVE STRATEGIES
• In cases of gingivitis and periodontal disease, chlorhexidine
mouthrinse may be useful.
• An increased recall frequency for patients having severe
dental disease is indicated.
• Anticipatory guidance about risk of trauma and TDIs as
patient with hearing impairment are at risk. Mouth guard
can be given and support with orthodontic treatment when
malocclusion is present. Also adequate knowledge on what
to do when TDIs occurs is important.
• Awareness of signs of abuse and mandated reporting
procedures

58. RECOMMENDATIONS
• Reducing the risk of developing oral disease is an integral
part of the comprehensive oral health care for children with
hearing impairment. The goals of care include:
• Establishing a dental home at an early age,
• Obtaining thorough medical, dental, and social patient
histories.
• It is useful that the dentist, while talking with the patient,
removes his face mask to facilitate the use of signs, gestures
and the interpretation of the lips to improve communication
with children with hearing disability.

59. RECOMMENDATIONS
• It would be useful for the dentist to learn, at least at a basic
level, sign language, and some ideograms to greet the
patient, receive them at the office, present with it and be
able to explain the treatment that is going to performed.
• For the first visit to the clinic, it is advisable to show them
books, pamphlets and visual materials like videos that offer
a realistic picture of this new situation.
• The dentist should explain everything that happens, since
the hearing disabled patient can be afraid of the unknown.
• They should be informed about instruments and equipment
vibrations letting them know it is normal.

60. RECOMMENDATIONS
• The sequence of work will always be show-say-do.
• Modeling is also very useful, noting the good behaviour of
another patient in order for them to imitate it.
• A handshake is a positive reinforcement for the patient and
one important way of expressing pleasure to them or
encourage them to go ahead with the treatment.
• It is of particular relevance that during their stay in the
dental practice the hearing impaired patient should feel
that members of the health care team are working calmly,
relaxed and they are treated with tact and amicably.

61. CONCLUSION
• A hearing impairment represents, for those who suffer, a
barrier in communication with the rest of society, especially
when receiving health care.
• The dentist must know and possess the necessary strategies
and tools to cope with this situation and successfully
achieve the proposed treatment objectives.

62. REFERENCES
• Cameron, A.C, Richard P.W. A Handbook of Pediatric Dentistry. 7th
Edition Edinburgh: Mosby, 2003.
• Labaeka AA, Tongo OO, Ogunbosi BO, Fasunla JA. Prevalence of
Hearing Impairment Among High-Risk Newborns in Ibadan,
Nigeria. Front Pediatr. 2018 Jul 16;6:194. doi:
10.3389/fped.2018.00194. PMID: 30062090; PMCID:
PMC6055064.
• Bimstein E., et al. Oral characteristics of children with visual or
auditory impairments. (2013) Pediatrics dentistry Journal Vol 36
pages 336-342
• Oredugba F.A, Sote E.O. Dental caries prevalence among
handicapped children in Lagos. (1999) Niger Postgraduate
Medical Journal. Vol 6, Page 122-125.
• Oredugba, F.A. Oral Health Care Knowledge and Practices of a
Group of Deaf Adolescents in Lagos, Nigeria. (2004) Journal of
Public Health Dentistry, Vol 64 page 118-
120. https://doi.org/10.1111/j.1752-7325.2004.tb02739.x

63. REFERENCES
• Champion, J., Holt, R. (2000) Dental care for children and young
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64. REFERENCES
• Cannobbio VC, Cartes-Velásquez R, McKee M. Oral Health and
Dental Care in Deaf and Hard of Hearing Population: A Scoping
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65. QUESTIONS & COMMENTS
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