Signs of care: ADA releases Dentist & Deaf Patients Guidance document

The sensory experience of a dental visit is not often something to look forward to. Our profession spends a great deal of time focusing on balancing comfort versus outcome, and we realise now how big a role that ‘soft skills’ such as communication can play in alleviating anxiety, and even pain management.

We also understand the powerlessness that patients can feel when their open mouth is being worked on and they are unable to speak and communicate as much as they’d like; increasing awareness of such topics as trauma-informed dentistry tell us that the background history of the individual can add further stressors.

So, take away another most common way to communicate – the sense of hearing – and it is logical that patients’ anxiety could rise.

Stepping up, skilling up

The heart of special needs dentistry (SND) lies in taking the time to understand the individual patient experience, then translating that empathy into practical steps to bridge any gap created between the patient’s wants and needs, and the clinical environment in which we treat them. With only a limited number of special needs dentistry specialists, it becomes clear that the bigger population of oral health practitioners in Australia must also rise to the occasion.

“We have only 29 registered special needs dentistry specialists in Australia. That’s not enough to cover the demand,” says Dr David Fu, a special needs dentist based in Queensland. “It means general dentists need to feel empowered to step up. If you can answer three questions – Where is this patient coming from? How do I treat them safely? Where are they going next? – then you’re on the right path. Simple things like facing the patient, speaking slowly, and not standing to the side can make a huge difference for someone using a hearing aid, for example, and that’s really what special needs dentistry is about. Small interventions can mean enormous changes in quality of life.”

Dr Fu has worked extensively with Deaf patients in his work in urban, rural and academic spaces. An impressive resumé, but his advice remains simple and workable: “The clinics that work best are the ones that involve the Deaf patient in decisions about their care — asking how they prefer to communicate, giving them options, and checking in often. That’s when trust builds.”

“The biggest thing is loss of control,” Dr Santarossa agrees, a Western Australian dentist who came to the fore in this space in 2023 with the launch of his co-project Smiling Signs, winner of a Mars Wrigley/Colgate Healthier Smiles grant when he was still a dental student. “Dentistry already takes away the ability to talk, and if you also can’t hear, the stress level doubles. That’s why I spend extra time before treatment, explaining everything while they can see my face. Once the mask goes on, lip reading goes out the window, and even facial cues are limited.”

How to begin?

Naturally, there is no getting around the use of PPE, and once a dentist begins to work in the mouth, their hands are unavailable for communication. So how does a general dentist without special needs training approach these practical challenges?

“The first step is preparation,” says Dr Fu. “I make sure I know in advance if a patient requires Auslan or an interpreter. If they do, I book through NABS, which is the National Auslan Interpreter Booking Service. They’re excellent, and it’s a free service for private healthcare appointments, so there’s really no barrier for dentists to use them.”

In the public system, Auslan interpreters are easy to organise and free; in private, it usually goes through the NDIS or NAATI (National Accreditation Authority for Translators and Interpreters; naati.com.au). If an interpreter isn’t required or available, resources such as the ADA’s new guidance document (see box, this page) can give you enough basics to take the next step towards inclusive care for patients on the Deaf spectrum.

In the clinic

Creating a welcoming environment for Deaf patients requires a few deliberate adjustments, but these can have outsized impact.

“The first thing is always eye contact,” says Dr Santarossa. “If you’re talking to a Deaf patient, look at them, not the interpreter. Facial expression is part of Auslan, so if you look away, they’re missing part of the meaning.”

“Layout is huge,” adds Dr Fu. “If the interpreter is behind me or in shadow, the patient can’t see them. I make sure the patient has clear sightlines to both me and the interpreter. Lighting, seating, where the nurse stands — it all matters.”

Indeed, working with interpreters in a clinical environment is another skill, but a few simple guidelines go a long way.

Clinicians should remember that interpreters are there to facilitate, not replace, the patient-dentist relationship.

“Interpreters are a bridge, but you have to remember the relationship is between you and the patient,” says Dr Santarossa. “Something people often misunderstand is whom to address. Some speak to the interpreter, saying things like, “Can you ask the patient if she can come next week?” Instead, you should act as if the interpreter is not there, apart from introducing yourself at the start. Speak directly to the Deaf patient, not the interpreter.

“The interpreter is not there to have opinions or to chat personally. It’s also important to know that the interpreter’s job is to interpret all noises and sounds, not just what you’re saying. For example, if a siren goes by outside, or someone yells from another room, the interpreter will inform the Deaf patient of what’s going on. If you’re talking to your nurse about your next holiday to Thailand, the interpreter will interpret that as well. So it’s important not to have conversations unrelated to the patient in front of them, just as you would be careful with any patient!”

“Remember also that interpretation is not the same as translation. Interpreters don’t provide a literal, word-for-word rendering. They provide context and meaning. Something you might say in five sentences may only take a handful of signs.”

Taking the time

Time management might not be the first thing that comes to mind when thinking about special needs dentistry, but for clinicians it is often the difference between an anxious situation and a comfortable, communicative appointment.

“We’ve found that even small things like sending a text reminder before the appointment – in clear, plain language – can set the tone,” suggests Dr Fu. “It shows that you’ve thought about accessibility before they even walk in the door.”

“Absolutely. Special needs patients need time. You can’t rush them,” Dr Santarossa adds, “and it’s not just the treatment time – it’s the preparation, the discussion, the reassurance. If you don’t allocate an extra 10 or 15 minutes, you’ll spend double that trying to calm a distressed patient later. The investment in time always pays off.

“I usually extend the appointment a little to allow for communication. At the start, I explain everything we’ll be doing – reclining the chair, raising it back up, what procedures are planned – so the patient knows what to expect. This reduces anxiety.

“I also establish some personal signs: for example, how I indicate ‘open’ and ‘close’, or moving the tongue side to side. I explain pain signals, like raising a hand, or giving a thumbs up if everything is okay. Once we’ve gone through all this, I don my PPE, recline the chair, and usually don’t need to speak much more. If I do, I sit the patient up, remove barriers, and talk face-to-face. I try to avoid conversation while the patient is lying flat, other than checking if they’re OK.

“Otherwise I’ll write things down, or type a quick note on a tablet, especially if something changes mid-procedure. And I’ll send written follow-ups afterwards so the patient leaves with clarity. Those small changes really build confidence for next time.”

Another practical point is to honour the appointment time. Deaf patients often book well in advance to secure an interpreter, and interpreters are usually contracted in two-hour blocks, even for short appointments. Last-minute changes can mean the interpreter can’t attend, which wastes time and resources. Respecting the schedule is important, because the interpreter may also have another job to go to immediately afterwards.

The joy of communication

“For the Deaf community, it’s important to understand they have a rich culture and history,” says Dr Santarossa, a point Dr Fu also makes. “It’s not just about Auslan – there’s poetry, literature, and other unique forms of expression.

“You don’t have to learn Auslan – though it would be great if you did – but becoming familiar with what deafness is, and recognising that it’s a wide spectrum, is key. Everyone has different communication preferences, and you can’t treat two people the same. Just being informed about the general differences within the community is a good place to start.

“The main thing is to have a go.

“In my experience, if I’m travelling overseas or treating a patient who doesn’t speak English, I often find it harder to communicate with them than with someone who is Deaf. That’s because Deaf people really make an effort to meet you halfway in communication. With other languages, it’s often either English or their language – there’s no middle ground. I find that Deaf people, on the other hand, are often resilient and creative.”

“I used to treat a lot of special needs patients even before I went into special needs dentistry,” says Dr Fu. “The core question for me was always: ‘am I doing the right thing for these patients?’ Doing my postgraduate degree really reinforced that there aren’t strict guidelines; often you’re working with principles of good care, doing the best you can. And if your intentions are good, you’ve already won half the battle.

“The new ADA guidance on Auslan is a great step. It gives simple, practical advice and basic Auslan words for dentists. I encourage everyone to read it. These resources weren’t taught at university – we’ve had to figure them out ourselves.

“These strategies aren’t just useful for Deaf patients but also for patients who are non-verbal for other reasons. It’s about creating any pathway to communication. I remember one Deaf patient in his 50s who told me, through an interpreter, that his old dentist never used an interpreter and never explained what was happening. He felt utterly helpless.

“That really struck me. In dentistry, we’re rapidly moving away from ‘drill and fill’ and toward patient connection. If we ignore communication, then we create anxiety. Too often that leads to sedation or GA as the default, when it can often be as simple as asking: what would make you feel more comfortable?

“That’s where trauma-informed care comes in. It’s about empowering patients to make decisions instead of us dictating treatment. It requires soft skills – empathy, patience, communication – but that’s where dentistry needs to go.”