Chapter 6: Ear, Eye, Nose, Throat, and Dental Health

Background

Access to consistent eye care, dental care, and hearing assessments is not always possible for low-income individuals, immigrants, and refugees. The costs of hearing aids, glasses/contacts, and dental work may not be feasible for low-income households. Essential items such as food and shelter may take precedence.

During hospitalization, health care providers (HCPs) can watch for subtle cues of vision and hearing loss and dental decay in their patients during daily assessments and interactions. With this information, HCPs can provide additional community support to patients with these types of issues.

Social Determinant Considerations and Culturally Responsive Practice Points for Health Care Providers

Eyes

Along with social and demographic considerations, African ancestry is a risk factor for primary open-angle glaucoma (Cole et al., 2021). Globally, primary open-angle glaucoma is the leading cause of irreversible blindness (Cole et al., 2021). Patients with African ancestry have thinner central corneas, which can lead to the inability to measure intraocular pressure accurately, and misdiagnosis (Cole et al., 2021).

Diabetic retinopathy is a microvascular complication of diabetes that causes visual impairment and even blindness (Lui et al., 2020). Along with blood sugar control, blood pressure is also an important risk factor in diabetic retinopathy (Lui et al., 2020). Diabetes and hypertension are more prevalent among certain cultural groups, and there are clear disparities in the diagnosis and treatment of these diseases (Lui et al., 2020). Please refer to the cardiovascular and endocrine sections of this text for further information. While caring for patients with diabetes and hypertension, HCPs should be vigilant in assessing for visual disturbances. See the list below for common signs of vision loss.

Black individuals are disproportionately affected by vision loss. They experience a greater impact on their quality of life and emotional well-being as a result (Grisafe et al., 2021). In their study, Grisafe et al. (2021) discovered that Black participants were mostly affected by their inability to complete visual tasks such as driving. Poor vision can also greatly impact an individual’s ability to participate in activities of daily living (ADLs) such as bathing, dressing, toilet hygiene, and other activities such as household chores, shopping, cooking, and transportation throughout the community (Umfress & Brantly, 2016). Vision loss may also lead to decreased participation in religious or social events, which could be very isolating for many individuals (Umfress & Brantly, 2016).

The World Health Organization (2022a) has stated that individuals from low- and middle-income settings have a greater burden of vision loss due to fewer opportunities to access eye care. In turn, these individuals may experience an even greater impact on their quality of life and ability to provide for and support family.

Furthermore, elderly people residing in care homes are significantly affected by visual loss and lack of diagnosis and treatment of various eye diseases (Umfress & Brantly, 2016). HCPs working in these institutions should be aware of the signs of vision loss and report them to primary care providers for diagnosis and treatment (Umfress & Brantly, 2016). Early diagnosis and treatment of eye diseases can reduce the risk of physical impairment produced by vision loss and increase quality of life (Umfress & Brantly, 2016).

During hospitalization, health care visits, or in care homes, HCPs can watch for signs of vision loss.

The Government of Canada (2017) has indicated that common signs of vision loss are:

• difficulty reading/writing
• squinting or tilting of the head and sensitivity to light
• misjudgment of where objects are (overreaching or underreaching)
• uncontrolled eye movement
• hesitancy with mobilization and experiencing frequent falls
• difficulties with ADLs, eating, and drinking
• withdrawal from social interactions

Ears

In their systematic review of published literature, Rouse et al. (2022) highlighted that Black, Latino, and Indigenous populations were underrepresented in the research on racial disparities in hearing-loss genetics. This indicates that there is minimal research or literature on genetic testing of hearing loss across cultures (Rouse et al., 2022).

Hearing loss is associated with other health conditions such as stroke, cancer, visual impairment, diabetes, arthritis, and cardiovascular risk factors (Besser et al., 2018). Many of these diseases are more prevalent among certain cultural groups (see the following sections of the text). Therefore, it can be inferred that hearing loss may disproportionately affect culturally diverse individuals.

Migrants and individuals of a lower socioeconomic status may experience a lack of hearing services and treatment of hearing impairment. In Saskatchewan, hearing tests are available through the Saskatchewan Health Authority for children, but are only available privately for adults (Government of Saskatchewan, 2021a). Hearing services and aids are expensive (up to $4,000.00 per ear). They may be partially covered by insurance (Government of Saskatchewan, 2021a). However, these costs are immense and individuals of a lower socioeconomic status may not be able to pay them.

HCPs should be vigilant in assessing for signs of hearing loss in patients during hospitalizations and health care visits or in care homes. If hearing loss is evident, HCPs can refer to their local health authority website or government website to refer patients to affordable or free hearing services in their area. Refer to the lists below for practice points on detecting hearing loss and communicating with patients who experience hearing impairment.

Canadian Hearing Services (2022) has indicated that common signs of hearing loss are:

• speaking louder than necessary
• constantly requiring statements to be repeated
• straining to hear
• favouring one ear more than the other
• withdrawing from conversations

Hearing loss negatively affects the patient’s ability to communicate with the HCP. It may also affect patient quality of care, patient outcomes, and patient satisfaction (Shukla et al., 2019). It is important for HCPs to acknowledge hearing impairment in their patients and adjust their communication techniques to the patient.

The Saskatchewan Health Authority (2021) has suggested strategies for communicating with individuals experiencing hearing impairment:

• Ensure the individual knows you are speaking to them by using their name at the beginning of the conversation.
• Face the patient and ensure they can see your mouth, face, and gestures. This may be complicated by using face masks in care areas.
• Ensure there is adequate lighting in the room for conversations.
• Reduce background noises.
• Speak slowly and clearly without shouting.
• Include the individual in group conversations. Do not talk as if the person is not present.
• When possible, supplement verbal conversations with writing and/or images.

Mouth, Nose, and Throat

Dental Health

Oral diseases are a major public health concern and have a negative impact on individuals, communities, and society (Peres et al., 2019). Oral health is not only important to overall physical health, but also closely linked to psychological and emotional health, allowing individuals to eat, speak, smile, and interact socially without embarrassment and discomfort (Peres et al., 2019). Oral diseases disproportionately affect individuals of a lower socioeconomic status. and have substantial adverse effects, such as pain, infection, decreased quality of life, and decreased attendance at work/school (Peres et al., 2019).

Dental caries (tooth decay) is one of the most common dental conditions and if left untreated, can cause significant pain and infection (Gupta et al., 2018). Dental caries have various causes and risk factors, including oral hygiene efficiency and food intake between meals (Cavallari et al., 2019). Mathur and Dhillon (2017) also indicated that dental caries can be caused by oral bacteria in dental plaque, the presence of fermented carbohydrates (sucrose), and available tooth surface. Mathur and Dhillon (2017) stated that one common dietary myth regarding dental caries is that only sugars and sweet foods can cause cavities; sticky and salty foods can also lead to caries. Furthermore, in their systematic literature review, Cavallari et al. (2019) argued that there is substantial evidence genetic factors are involved in the development of dental caries. These genetic factors can lead to some individuals carrying certain genes that make them more susceptible to developing dental caries with the aforementioned risk factors. Regular dental visits can greatly reduce the instances of dental caries and allow for treatment before conditions worsen (Gupta et al., 2018).

When patients are hospitalized or in long-term care, HCPs can assess for dental caries using the list of signs and symptoms below.

The Mayo Clinic (2022) has indicated that signs of cavities and tooth decay are:

• tooth pain upon biting down
• tooth sensitivity to sugary, cold, or hot foods/drinks
• visible holes or pits in teeth
• brown, black, or white staining on tooth surfaces

There are many barriers to regular dental care including finances, health literacy, access to resources, understanding of the health care system, and language barriers (Gupta et al., 2018; Han, 2019). In Saskatchewan, routine dental care services for adults are not covered. Coverage is only available for specific procedures involving emergency care (Government of Saskatchewan, 2021b). It is important for HCPs to view the government and health authority websites in their areas of practice to understand the available services and public health initiatives. HCPs can use promotional strategies to educate patients and direct them to these services.

The World Health Organization (2022b) has suggested the following strategies to prevent oral diseases:

• promoting a well-balanced diet, low in free sugars and high in fruits/vegetables
• increasing consumption of water in comparison to beverages with added sugar
• smoking cessation
• reducing alcohol intake
• using protective mouth gear to prevent oral injuries during sports
• ensuring adequate exposure to fluoride (through fluoridated drinking water, salt, milk, and toothpaste)
• brushing teeth twice a day

Orofacial Clefts

Orofacial clefts include cleft lip, cleft palate, and cleft like with cleft palate (WHO, 2022b). The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) (2020) reported that orofacial clefts occur in approximately 1 out of 1,500 births, with variations in different studies and populations. A major cause of this defect is a genetic predisposition (WHO, 2022b), with a higher prevalence in people of Northern European, Indigenous, and Asian ancestry (WHO & CDC, 2020). Along with genetic causes, orofacial clefts at birth are also associated with maternal smoking, alcohol consumption, and use of certain medications such as barbiturates (WHO & CDC, 2020). Additional risk factors include pregestational diabetes, systemic steroid use, and consumption of substances that are folic acid antagonists (WHO & CDC, 2020).

If orofacial clefts are treated early with surgery, complete rehabilitation is possible (WHO, 2022b). Unfortunately, ethnicity and low socioeconomic status play a significant role in both primary and revision surgeries (Wu et al., 2019). If left unrepaired, orofacial clefts can lead to feeding problems, failure to thrive, speech issues, airway problems, infections, depression, and substantial psychological issues (Wu et al., 2019). Furthermore, Wehby et al. (2015) determined that children with an orofacial cleft were more likely to achieve lower academic scores. The age at which patients undergo surgical repair is very important. Older patients often require more extensive and painful surgeries with a higher risk of complications (Wu et al., 2019). Through their research, Wu et al. (2019) revealed that White patients have primary cleft palate repair at an earlier age and experience fewer complications, shorter lengths of stay, and lower costs compared to racial minority groups.

Dysphagia

Dysphagia is a swallowing condition that can occur in patients after strokes or other chronic illnesses. Dysphagia can lead to various serious complications such as choking episodes, aspiration pneumonia, dehydration, and malnutrition (Kenny, 2015). Food is an important part of life, and food choices can reflect spiritual beliefs, cultural norms, and life experiences. A diagnosis of dysphagia can have a negative impact on not only the nutritional status but also the psychological well-being of an individual (Kenny, 2015). In some cultures, food can only be prepared in a certain way. Changing the texture and consistency of foods may not be acceptable to some patients, and patients may risk consuming foods that are unsafe (Kenny, 2015). It is important to have open conversations with patients and families to understand their views on food. It is also important to work together to support autonomy and facilitate positive health outcomes, with the common goal of patient safety (Kenny, 2015).

HCP’s can review government websites in their areas of practice to understand which services are covered or partially covered. It is also important to review local health authority websites for health promotion strategies within the community. HCPs should collaborate with assigned social workers, as they may know of additional services within the community. These types of support can be provided to patients in need of eye, ear, nose, throat, and dental services.

References

Besser, J., Stropahl, M., Urry, E., & Launer, S. (2018). Comorbidities of hearing loss and the implications of multimorbidity for audiological care. Hearing Research, 369, 3–14. https://doi.org/10.1016/j.heares.2018.06.008

Canadian Hearing Services (2022). Hearing loss. https://www.chs.ca/hearing-loss

Cavallari, T., Arima, L. Y., Ferrasa, A., Moysés, S. J., Moysés, S. T., Herai, R. H., & Werneck, R. I. (2019). Dental caries: Genetic and protein interactions. Archives of Oral Biology, 108, 104522. https://doi.org/10.1016/j.archoralbio.2019.104522

Cole, B. S., Gudiseva, H. V., Pistilli, M., Salowe, R., McHugh, C. P., Zody, M. C., Venkata, R. M., ShuangYing , G., Moore, J. H., & O’Brien, J. M. (2021). The role of genetic ancestry as a risk factor for primary open-angle glaucoma in African Americans. Investigative Ophthalmology & Visual Science, 62(2), 28. https://doi.org/10.1167/iovs.62.2.28

Government of Canada (2017, April 4). Seniors and aging: Vision care. https://www.canada.ca/en/health-canada/services/healthy-living/your-health/lifestyles/seniors-aging-vision-care.html

Government of Saskatchewan (2021a). Audiology and hearing services. https://www.saskatchewan.ca/residents/health/accessing-health-care-services/audiology-and-hearing-services

Government of Saskatchewan (2021b). Partially covered services. https://www.saskatchewan.ca/residents/health/prescription-drug-plans-and-health-coverage/health-benefits-coverage/partially-covered-services

Grisafe II, D. J., Varma, R., Burkemper, B. S., Xu, B. Y., Torres, M., Fairbrother-Crisp, A., Patino, C. M., & McKean-Cowdin, R., for the African American Eye Disease Study Group. (2021). Impact of visual field loss on vision-specific quality of life in African Americans: The African American eye disease study. American Journal of Ophthalmology, 229, 52–62. https://doi.org/10.1016/j.ajo.2021.02.008

Gupta, N., Vujicic, M., Yarbrough, C., & Harrison, B. (2018). Disparities in untreated caries among children and adults in the US, 2011–2014. BMC Oral Health, 18(1), 1–9. https://doi.org/10.1186/s12903-018-0493-7

Han, C. (2019). Oral health disparities: Racial, language and nativity effects. SSM Population Health, 8, 100436. https://doi.org/10.1016/j.ssmph.2019.100436

Kenny, B. (2015). Food culture, preferences, and ethics in dysphagia management. Bioethics, 29(9), 646–652. https://doi.org/10.1111/bioe.12189

Liu, L., Quang, N. D., Banu, R., Kumar, H., Tham, Y. C., Cheng, C. Y., Yin Wong, T., & Sabanayagam, C. (2020). Hypertension, blood pressure control and diabetic retinopathy in a large population-based study. PLoS One, 15(3), e0229665. https://doi.org/10.1371/journal.pone.0229665

Mathur, V. P., & Dhillon, J. K. (2018). Dental caries: a disease which needs attention. The Indian Journal of Pediatrics, 85(3), 202–206. DOI: 10.1007/s12098-017-2381-6

Mayo Clinic (March 19, 2022) Cavities and tooth decay: Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/cavities/symptoms-causes/syc-20352892

Peres, M. A., Macpherson, L. M., Weyant, R. J., Daly, B., Venturelli, R., Mathur, M. R., . . . & Watt, R. G. (2019). Oral diseases: a global public health challenge. The Lancet, 394(10194), 249–260. https://doi.org/10.1016/S0140-6736(19)31146-8

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Saskatchewan Health Authority (2021, September 8). Hearing loss. https://www.saskhealthauthority.ca/your-health/conditions-diseases-services/healthline-online/hw107979#acl9751

Shukla, A., Nieman, C. L., Price, C., Harper, M., Lin, F. R., & Reed, N. S. (2019). Impact of hearing loss on patient–provider communication among hospitalized patients: A systematic review. American Journal of Medical Quality, 34(3), 284–292. https://doi.org/10.1177/1062860618798926

Umfress, A. C., & Brantley Jr., M. A. (2016). Eye care disparities and health-related consequences in elderly patients with age-related eye disease. Seminars in Ophthalmology, 31(4), 432–438. https://doi.org/10.3109/08820538.2016.1154171

Wehby, G. L., Collett, B. R., Barron, S., Romitti, P., & Ansley, T. (2015). Children with oral clefts are at greater risk for persistent low achievement in school than classmates. Archives of Disease in Childhood, 100(12), 1148–1154. http://dx.doi.org/10.1136/archdischild-2015-308358

World Health Organization, National Center on Birth Defects and Developmental Disabilities, & International Clearinghouse for Birth Defects Surveillance and Research (2020). Birth defects surveillance: A manual for programme managers (2nd ed.). World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/337425/9789240015395-eng.pdf

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Wu, R. T., Peck, C. J., Shultz, B. N., Travieso, R., & Steinbacher, D. M. (2019). Racial disparities in cleft palate repair. Plastic and Reconstructive Surgery, 143(6), 1738–1745. DOI: 10.1097/PRS.000000000000565