6 Shivanna, V., Jain, Y., Valluri, R. et al. (2019). Estimation of dental anxiety levels before and after dental visit in children with visual impairment using modified dental anxiety scale in Braille text. J. Int. Soc. Prev. Community Dent. 10: 76–84.
7 Tiwari, B.S., Ankola, A.V., Jalihal, S. et al. (2019). Effectiveness of different oral health education interventions in visually impaired school children. Spec. Care Dentist. 39: 97–107.
8 Watson, E.K., Moles, D.R., Kumar, N., and Porter, S.R. (2010). The oral health status of adults with a visual impairment, their dental care and oral health information needs. Br. Dent. J. 208: E15.
3.2 Auditory Deficit
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 6‐year‐old girl presents to your dental clinic with her foster mother who requests management of the patient's dental crowding.
Medical History
Foetal alcohol syndrome (her biological mother had a drug and alcohol addiction, and is deceased)
Bilateral mixed hypoacusis/hearing impairment due to sensorineural damage and eustachian tube dysfunction; auditory thresholds of 90 dB in the right ear and 80 dB in the left ear; has worn hearing aids from the age of 8 months but finds these difficult to tolerate
Pigmentary retinopathy and optic nerve hypoplasia resulting in partial visual impairment
Osteopenia in the lumbar vertebrae
Overall growth retardation, with mild intellectual deficit
Behavioural issues, with occasional aggressive episodes
Medications
Risperidone
Vitamin D3
Dental History
No previous dental visits
No chewing or swallowing problems
Patient brushes 3 times a day, supervised by her foster mother
Social History
Lives with a foster family
Lack of spoken language but communicates through sign language
Schooled since the age of 4 years (has a specialised support teacher for deaf‐blind children)
Oral Examination
Good oral hygiene
Bimaxillary compression resulting in a narrow, pointed/ogival arched palate (Figure 3.2.1)
Posterior cross‐bite; edge‐to‐edge occlusion of anterior teeth
Anterior tooth crowding, both maxillary and mandibular
Delayed tooth eruption
No caries detected
Radiological Examination
An orthopantomogram was performed (poor quality due to lack of patient co‐operation)
Demonstrated delay in dental development and tooth eruption of approximately 18–24 months
Agenesis of #34, #35, #44 and #45
Structured Learning
1 Why is the hypoacusis/loss of hearing in this patient particularly significant?The patient has mixed bilateral deafness (which implies sensorineural impairment)The auditory threshold is very low in one ear and severe in the otherThe onset of the deafness was prelingual
2 What other factors impact on the ability to communicate with this patient?Does not tolerate her hearing aids (often removes them)Additional visual deficit which will impact on her ability to:Figure 3.2.1 Bimaxillary compression resulting in a narrow, pointed/ogival arched palate.Engage with other communication management techniques such as pictograms and ‘tell–show–do’ (Figure 3.2.2)Ability to lip read or use sign language effectivelyNo prior dental experience so unable to relate to surroundings, including the feel and smells associated with a dental officeLearning disabilityFigure 3.2.2 Sign language can be used to enhance communication.Behavioural issues which may be worsened by heightened anxiety
3 What factors are considered important in assessing the risk of managing this patient?SocialLack of spoken languageLimited co‐operationPotentially aggressive behaviourMedicalAuditory deficitVisual deficitIntellectual deficitDentalNo previous experience of dental visits and hence limited co‐operation; will require acclimatisationCertain behavioural control techniques are not applicable (e.g. tone of voice)Delayed dental development, malocclusion, tooth agenesis and high arched palate in relation to the foetal alcohol syndrome
4 The foster parent explains that the child is being bullied at school because she looks different. What would you do?Discuss that improving the appearance of the child's teeth may not stop the bullying as the child may have other distinctive facial features of foetal alcohol syndrome which may appear different (small eyes, thin upper lip, short, upturned nose and a smooth skin surface between the nose and upper lip)Explain that the child is too young for dental extractions, orthodontics and/or orthognathic surgery to be planned (she is in the mixed dentition stage)She also has limited co‐operationThe most important focus is to acclimatise her to visiting the dentist regularly so that her oral health can be maintained and enable more invasive treatment at a later stageEncourage the foster parent to discuss the bullying with the school and social services
5 Tooth crowding in anterior sectors has promoted the localised accumulation of dental calculus. What factors would you need to consider when choosing the appropriate technique for removal of these deposits?Manual instruments (curettes) may be preferable to minimise the background noiseUltrasonic instrumentation can cause interference with hearing aids
6 The patient is not co‐operative for calculus removal. What factors are important to assess prior to the adjunctive use of inhalational sedation?
The nasal hood may not be tolerated or may have a further negative impact on communication
Sedation itself may further impede communication
The patient has developmental delay – it is important to consider her weight and height before deciding on the appropriate concentration
Risperidone and nitrous oxide both have CNS depressant effects
General Dental Considerations
Oral Findings
The prevalence of caries and the decayed, missing and filled teeth (DMFT) index in children with deafness are determined by their age, socio‐economic level and educational level of their parents
Children and adolescents with and without auditory deficit, whose oral health is supervised, have a similar prevalence of caries
An increased rate of dental trauma