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Overcoming communication barriers between dental providers and persons with aphasia: An educational training
*Corresponding author: Maya Noelle Feaheny Moskal, University of Kentucky College of Dentistry, Lexington, Kentucky, United States. mnfe224@uky.edu
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Received: ,
Accepted: ,
How to cite this article: Feaheny Moskal MN, Page CG. Overcoming communication barriers between dental providers and persons with aphasia: An educational training. J Academy Dent Educ. doi: 10.25259/JADE_23_2025
Abstract
Objectives:
Dental-related fear and anxiety are common. This is especially true for individuals with aphasia who may have difficulty reading, writing, listening, and/or speaking. Conversations between a patient and the provider may reduce these hardships. When communication is limited, challenges arise, and patients avoid routine dental visits in addition to needed dental treatment. Many of the communication barriers relate to a lack of knowledge and education on effective communication strategies. The implementation of an educational video on dentistry and aphasia is believed to be one way to combat this. This study aims to identify whether an educational video improves knowledge and confidence about communication strategies for individuals with aphasia.
Material and Methods:
22 dental hygiene students participated in a pre-survey, 35-min educational video, and a post-survey.
Results:
It was found that four (4, 5, 8, 9) of the seven questions that were statistically analyzed showed significance between pre- and post-survey answers. Two questions were not statistically analyzed (10, 11), as the correct response rate was 100% in the pre- and post-surveys. Students’ subjective responses after watching the educational video revealed an increase in self-confidence and knowledge as well.
Conclusion:
The present study found that in general, the provided educational training was effective at increasing students’ knowledge about best communication practices for working with persons with aphasia, in addition to increasing their confidence levels when doing so.
Keywords
Aphasia
Communication barriers
Dental anxiety
INTRODUCTION
Dental fear is a feeling of anxiety when visiting the dentist and receiving dental cleanings and/or treatment. In the general population, dental fear and dental anxiety are very prevalent.[1] According to Silveira et al. (2021), 15.3% of people experience dental fear and anxiety, 12.4% experience high dental fear and anxiety, and 3.3% of people experience severe dental fear and anxiety.[1] For those with special needs, dental fear is the most common barrier to treatment.[2,3] High dental fear and anxiety lead to many factors that contribute to a lower oral health-related quality of life.[4] Dental fear is inversely correlated with dental attendance, meaning those with higher levels of fear and anxiety tend to avoid going to the dentist more often than those without dental fear.[5]
There are many methods to alleviate patient fear and anxiety, ranging from establishing good communication to guided imagery and cognitive restructuring.[6] It has repeatedly been shown that dentist–patient communication is vital for positive patient outcomes.[3,4,7] High levels of dental anxiety and mistrust are commonly due to negative communication between the patient and dentist.[7] In contrast, patients who experience positive communication with their dentist tend to show higher levels of dental literacy, lower levels of anxiety and mistrust, and higher overall satisfaction.[7] When patients evaluate a dentist–patient interaction higher than the dentist evaluates it, patient outcomes are more positive.[8] Similarly, when the dentist evaluates the interaction higher than the patient, patient outcomes are worse.[8]
While communication has been shown to minimize dental fear and anxiety, many people are living with communicative hardships such as aphasia. At present, over two million people have aphasia in the United States.[9] Aphasia is an acquired disorder that results from brain damage, ranges in severity, and can affect a person’s ability to read, write, speak, and understand language. A clear understanding of their communication needs and adaptations requires collaboration with a speech-language pathologist. Speech-language pathologists can provide specific communication techniques to enhance the dental care experience. This interprofessional collaboration can begin in the classroom. Most dental providers are unaware of communication methods for people with communication hardships, and there is very limited published research on aphasia in the dental setting. Previous research identifies a need for general anesthesia for patients with developmental and intellectual disabilities, including aphasic patients as a significant portion of the subject pool.[10] However, aphasia does not affect one’s intelligence or development,[11] so the limited existing research is questionable. Other existing research discusses methods of communication with patients who have special needs.[2,3,12] In general, research incorporating aphasia into dental education is limited. Furthermore, no known training on the use of communication strategies for the dental setting is available.
This study sought to determine the impact of aphasia education on dental hygiene students’ awareness and knowledge of aphasia. The goal of the education is to increase providers’ knowledge and chairside confidence for treating patients affected with aphasia, to in turn alleviate patient fear and anxiety.
MATERIAL AND METHODS
Study design
This study used design-based research (DBR) methodology[13] to determine the validity of educational modules. DBR uses an iterative process within the context of education to develop applicable educational practices. The three processes of DBR include (1) analysis and exploration, (2) design and construction, and (3) evaluation and reflection.[14]
Analysis and exploration involve identifying a problem and analyzing the available resources/literature. The problem in this study relates to the fear of dentistry by individuals with aphasia as well as the reduced communication training of dental professionals.
Design and construction involve creating the intervention. In this study, a module with educational videos about aphasia and communication strategies was designed and constructed. The educational training aimed to enhance the dental care experience. A 35-min educational training consisting of multiple modules was developed. The modules in Video 1 were provided to participants and included information about what aphasia is, the importance of communication and interprofessional collaboration in dentistry, a series of communication strategies, and a discussion on the importance of chair-side confidence. Fifteen communication tactics were introduced to students, adapted from Marshall and English (2004), and included linguistic, temporal, and total communication strategies.[15]
Evaluation and reflection involve assessing the outcomes of the intervention (training) and reflecting on positive and negative results. In this study, dental hygiene students completed a pre-test, viewed the modules, and completed a post-test.
Video 1:
Video 1:This video is original and was provided to participants as their source of education in this study. Video available at: https://dx.doi.org/10.25259/JADE_23_2025 (source: https://youtu.be/3k-l56Cf6xg)Participant inclusion
Before participant enrollment, the protocol was approved by the University of Kentucky’s Institutional Review Board. Participants were selected based on a convenience sample. All were actively enrolled in a dental hygiene program.
Procedures
First, students completed an anonymous consent form, acknowledging that their participation is voluntary and they can abandon participation at any point. Second, students completed a pre-survey, consisting of 11 true/false, short answer, and sliding scale questions. Third, students watched the 35-min educational video. Finally, students completed a post-survey, consisting of 13 true/false, short answer, and sliding scale questions. Surveys were administered through Qualtrics, and the educational video was shared through YouTube. All students in the program were given 2 weeks to complete all steps in exchange for extra credit points in their program.
Anonymity was maintained throughout the entire protocol. After agreeing to participate, students created an individualized and non-identifying 4-digit code that they used on the pre-and post-survey. It was through the codes that data were analyzed, and responses were ensured to be valid and accurate.
In the pre- and post-surveys, Questions 1 and 2 asked students for their 4-digit code and whether they have watched the educational video yet. Questions 3, 4, 6-11 were True/False, and Question 5 was short answer:
Question 3: I have heard the term “aphasia” before today
Question 4: I can define the term “aphasia”
Question 5: Please define the term “aphasia” to the best of your ability. [if “true” was selected in question 4]
Question 6: Aphasia is a rare disorder
Question 7: Aphasia affects oral and written communication
Question 8: Aphasia alters intelligence
Question 9: There is no cure for aphasia
Question 10: Aphasia only impacts the person diagnosed
Question 11: Fear and anxiety around dentistry lead many people to avoid going to the dentist
Question 12 was a sliding scale question and asked students, 0 (low) - 10 (high), to rank their confidence in communicating with a person with aphasia.
In the post-survey, two additional questions were added that were not in the pre-survey, as they were only applicable post-education. Question 13 asked students to list and describe one communication strategy they learned about and an example of how to use it. Question 14 asked students to rate how well the educational training taught them information they did not already know.
Analysis
A paired samples t-test was completed for questions 3–9 to identify statistical differences between participants’ knowledge and confidence about aphasia before and after the educational training.
Question 5 (Please define the term “aphasia” to the best of your ability) was included in the pre- and post-survey if students responded “yes” to Question 4 (I can define the term “aphasia”). To reduce bias, responses to Question 5 were randomized and blindly graded based on the following criteria:
Defines aphasia as a disorder or problem
Defines aphasia as impacting speech and written language
Defines aphasia as impacting the ability to understand language
Defines aphasia as being acquired, rather than congenital.
For a definition to “pass,” it must have included at least 3 of the 4 above criteria. Definitions received a “high pass” if they indicated that the cause of aphasia is brain trauma. Definitions “failed” if they included <3 of the above criteria.
RESULTS
Two students submitted the pre-survey twice. Thus, there were 24 pre-surveys and 22 post-surveys. To simplify results and standardize pre- and post-comparison, one of each duplicate pre-survey was randomly selected to be discarded. In the end, there were 22 participants who completed all steps of the training and surveys.
Statistical analysis revealed that four of the seven questions (questions 4, 5, 8, and 9) showed statistically significant differences in pre and post-test scores with a P ≤ 0.005. Three of the questions did not reach statistical significance. Table 1 includes the paired differences and statistical significance for each question.
| Question (True/False) | Mean | Standard deviation | Standard error mean | P-value |
|---|---|---|---|---|
| 3 - I have heard the term aphasia before today | −0.045 | 0.213 | 0.045 | 0.164 |
| 4 - I can define the term “aphasia” | −0.318 | 0.477 | 0.102 | 0.003* |
| 5 - Define the term “aphasia” to the best of your ability | −0.591 | 0.503 | 0.107 | <0.001* |
| 6 - Aphasia is a rare disorder | −0.182 | 0.395 | 0.084 | 0.021 |
| 7 - Aphasia affects oral and written communication | −0.045 | 0.213 | 0.045 | 0.164 |
| 8 - Aphasia alters intelligence | −0.318 | 0.477 | 0.102 | 0.003* |
| 9 - There is no cure for aphasia | −0.318 | 0.477 | 0.102 | 0.003* |
For questions 10 (aphasia only impacts the person diagnosed) and 11 (fear and anxiety around dentistry lead many people to avoid going to the dentist), all participants correctly responded on both the pre- and post-tests, not warranting statistical analysis.
For question 12 (I am confident in my ability to effectively communicate with a person with aphasia), the difference in pre and post-ratings was statistically significant (P < 0.001). Before the training, students reported a mean confidence level of 4.36 (standard deviation [SD]: 2.150, standard error mean [SEM]: 0.458). After the training, students reported a mean confidence level of 8.36 (SD: 1.002, SEM: 0.214).
Questions 13 and 14 were only given after the training. In Question 13, 21 of 22 participants were able to successfully describe a communication strategy after the educational video. In Question 14, all participants strongly agreed (19) or somewhat agreed (3) that this training taught them new information.
DISCUSSION
It is widely recognized that dental fear is prevalent in society. As communication is a common fear-relief, people who have impaired communication abilities are at risk for decreased willingness to receive dental care. This study sought to inform students in the dental field about aphasia and provide them with communication strategies to use in future dental practice.
In general, this training was effective at increasing students’ knowledge and confidence in working with persons with aphasia in the dental setting. Following the training, there was a significant increase in student knowledge/confidence in five of the questions asked. Questions 4 and 5 assessed students’ ability to define the term “aphasia.” While there was no significance in students’ knowledge of the term “aphasia” (Question 3), students were significantly more able to define the term after watching the educational training as compared to before the training (Questions 4, 5).
Questions 6–11 assessed students’ general knowledge about aphasia through true/false questions. In Questions 8 and 9, students’ responses were significantly more accurate after the training. Question 12 was subjective, assessing students’ confidence in their ability to effectively communicate with a person with aphasia. After the training, students were significantly more confident in their ability as compared to before the training.
In Question 7, all students but one answered the question correctly in the pre-survey, and all students answered correctly in the post-survey. For Questions 10 and 11, all students answered correctly in both the pre- and post-surveys. It is likely that these questions were not significantly different before and after the training due to students’ previous knowledge. For example, the students completing this training are in the dental field and are aware of fear and anxiety prevalence in patients; therefore, it is logical that all students answered Question 11, about dental fear/anxiety, correctly. Questions 3, 6, and 7 did not reach statistical significance with a P < 0.005. There were no questions where students were incorrect in the pre-survey and were still incorrect in the post-survey, which would indicate no change in learning. Rather, for all questions where students were incorrect in the pre-survey, there was a significant improvement in scores demonstrated in the post-test. This study had multiple strengths. There is a gap in the literature about dentistry and aphasia, and there is a need for more education. This is the first educational training to our knowledge for dental professionals about aphasia. In addition, the participants in this study were the target audience for this training. It is intended for the educational training to be integrated into the dental curriculum, and its significance in multiple areas is impactful.
One major limitation of this study is the discarding of two duplicate pre-survey responses. This was necessary to ensure the results and data analysis were accurate; however, the duplicate-coded pre-surveys did not have identical responses. For each duplicate code, one of the two submitted surveys was randomly discarded. Another limitation of this study is that the sample population is students. With gained dental experience, a provider of 20 years would have more natural experience communicating with patients than a student with no experience. Furthermore, validation of viewing the educational training was not confirmed. Furthermore, the population of students was lightly controlled. No personal data were collected from students, meaning they could have been different ages, had varying life experiences with aphasia, and therefore knowledge levels entering the study; none of which is known due to anonymity.
It is worth noting that the sample population for this study was small. This is due to the exploratory nature of the study and the intention to identify patterns and trends, rather than generating large-scale research. Subsequent modifications to the educational training will be based on the initial trends noted from this study.
CONCLUSION
The present study found that this educational training was effective at increasing students’ knowledge about and confidence in working with persons with aphasia. In alignment with the design-based methodology template followed in the study, this educational training will be modified based on the results of this study. Aspects that were not significant will be altered to have a greater impact on students and provide only the necessary information. Due to success and significance in multiple areas, it is intended that the training is integrated in more dental programs as an emphasized and important aspect of the curriculum.
Acknowledgment:
Gratitude is extended to Mary W Jones, Dental Hygiene Program Coordinator, for assistance with data collection and communication with participants. Without her support, this study would not have been possible.
Ethical approval:
The research/study was approved by the Institutional Review Board at the University of Kentucky, number 95735, dated 01st November 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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