ADRF RESEARCH REPORT
Australian Dental Journal 2005;50:(4):235-241
Dentist-patient communication in the multilingual dental
setting
C Goldsmith,* L Slack-Smith,† G Davies‡
Abstract
Background: Communication between dentists and
patients can be exceptionally challenging when the
patient and the dentist do not speak the same
language, as is frequently the case in multicultural
Australia. The aim of this study was to describe the
issues involved in dealing with limited-English
speaking patients in order to formulate
recommendations on how to improve dental
communication.
Methods: A cross sectional study was performed
using a postal survey to Australian Dental
Association member dental practitioners in Western
Australia. Responses were collated and data analysis
was performed using SPSS 11.5 for Windows.
Results: Most respondents encounter language-
related communication barriers weekly or monthly,
and the most satisfactory method of communication
is informal interpreters. Despite reporting
satisfaction working with professional chairside
interpreters or dental staff interpreters, most
respondents did not use them. The most common
alternative communication methods were diagrams
and models. Endodontics and periodontics provided
the greatest challenge in communication. Informed
consent was reportedly compromised due to
language barriers by 29 per cent of respondents.
Recommendations to improve communication
included access to interpretation services, dentist
technique/attitude to communication and patient
preparedness for English-speaking encounters.
Conclusions: Many respondents do not utilize the
preferential communication methods, creating a
potential compromise to both informed consent and
the patients’ best interests. The use of professional
interpreters is recommended, and discussion should
be supplemented with means of non-verbal
communication. Dentists require access to lists of
multilingual dentists and greater awareness of
interpretation services to improve multilingual
dentist-patient communication.
*Dentistry Student, School of Dentistry, The University of Western
Australia.
†Senior Lecturer in Oral Epidemiology, School of Dentistry, The
University of Western Australia.
‡Senior Lecturer, School of Dentistry, The University of Western
Australia.
Australian Dental Journal 2005;50:4.
Key words: Communication, languages, dental patient.
Abbreviations and acronyms: ABS = Australian Bureau of
Statistics; ADA = Australian Dental Association.
(Accepted for publication 7 March 2005.)
INTRODUCTION
In the multicultural population that defines
Australian society, it is likely that dentists will
encounter patients in the clinical dental setting who do
not speak English. Such situations are liable to create
additional communication barriers which can
compromise patient treatment and satisfaction. There is
a dearth of Australian research regarding the dentist’s
perspective on the treatment of patients who speak a
language other than English. Research conducted in
Britain suggests that language barriers are often
identified as the most frequent impediment to dental
care.1 This is likely to be due to a lack of understanding
of the patient’s explanation of a problem, obtaining a
medical history and gaining informed consent.
Inadequate communication may place patient health at
risk, restrict treatment options, and provide a potential
for litigation.1 Research in the medical field on doctor-
patient communication suggests that effective
communication can improve measures of health care
such as patient satisfaction, adherence to treatment and
disease outcomes.2,3
An investigation into migrant dental health4 found
that overseas born persons who speak a language other
than English are more likely to attend a dentist for
management of a specific problem rather than a check-
up and are also more likely than Australian born
persons to be dissatisfied with dental care received.
Generally, migrants may be disadvantaged in terms of
their health and/or access to services. Specifically,
language barriers appeared to be a greater disadvantage
than being overseas born in accessing preventive dental
care and dental care that the patient found satisfactory.4
Consent in dental practise is both an ethical obligation
and a legal requirement,5 but consent obtained across a
language barrier without competent interpretation is
235

unlikely to be truly informed.6 Failure to communicate
adequately has been determined as the source of
negligence in several United States medical law cases.6
A clinical encounter relies primarily on verbal
communication,3 and various means of interpretation
may be employed in achieving this. The use of
interpreters is recommended when doctor-patient
communication is limited by language difficulties.7
There exists a potential for breach of confidentiality
and risk of misinterpretation by using an informal
interpreter (i.e., a family member or friend) who is not
independent and professional.1,8,9 Communication
problems can be costly and time consuming for both
practitioners and patients and there may be limited
tolerance for measures of communication which delay
the treatment process, e.g., telephone interpreters.8
The aim of this study was to investigate dentists’
views regarding the provision of dental care to persons
who speak limited English. This included assessing the
demographic characteristics of dentists and dental
patients and current approaches to communication.
MATERIALS AND METHODS
Ethical approval for this study was granted by The
University of Western Australia Human Research
Ethics Committee. All research was conducted
according to the National Health and Medical
Research Council guidelines.
A questionnaire was devised then distributed with
the Western Australian (WA) branch of the Australian
Dental Association (ADA) Newsletter in March 2004.
Reply paid envelopes were included with the
questionnaire. Recipients were asked in a covering
letter to complete the questionnaire, informed that
replies would be treated in confidence and given
contact details should they have any queries or
concerns regarding the proposal.
In the questionnaire, the recipients were asked what
languages they spoke, what languages were
encountered in clinical practise, the frequency with
which these were encountered, and problems with
specific language groups. Participants were also asked
which methods of communication were used and
satisfaction or dissatisfaction with each. Information
regarding costs involved, issues surrounding informed
consent and suggestions for improvements in
communication were also requested. Questions were
designed for Likert-type responses where results could
be quantified. Questions requiring written answers
were designed so that responses were grouped
according to similar themes to allow detection of
common trends.9 The results were received by mail and
data were collated and analysed using SPSS 11.5 for
Windows. Missing values were excluded in the analysis.
RESULTS
Demographic characteristics
There were 120 questionnaires returned, which is a
response rate of 13 per cent. The results represent the
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responses of a proportion of members of the Australian
Dental Association (WA). General dental practitioners
made up 77 per cent of respondents with the remainder
being specialists or community dentists. Of the
respondents, 65 per cent reported proficiency in the
English language only, 35 per cent reported proficiency
in English and at least one language other than English.
The survey revealed that a higher proportion of
respondents spoke a language other than English
compared to the general population. This may relate to
the country of birth with 52 per cent of respondents not
born in WA. The place of graduation of 97.5 per cent
of respondents was from countries with English as the
official language. Most graduated within Australia,
with the next most significant proportion from the UK.
Most respondents indicated that the percentage of
patients who spoke inadequate English for a dental visit
comprised less than 10 per cent of all clients. However,
the percentage of such patients was reported to be as
high as 40 per cent in some practices.
Respondents’ perceptions of language groups and
methods of communication
The majority of respondents experience language-
related communication barriers with patients weekly to
monthly. Most respondents recognized that a
proportion of their patients (even if quite small), do not
speak adequate English, and 15 per cent of respondents
reported that they never encounter such barriers.
According to the survey, the most common language
groups encountered are Italian (49 per cent), Chinese
(25 per cent) and Vietnamese (13 per cent). Similar
groups are reported as presenting the most difficulty to
dentists, the most commonly listed being Asian, Italian
and Chinese.
The most satisfactory method of communication with
a non-English speaking patient was reported to be
informal interpreters. This method rated ‘high’ or ‘very
high’ in terms of satisfaction by 64 per cent of
respondents. This is much greater than the next most
satisfactory, chairside formal interpreters which rated
‘high’ or ‘very high’ by 34 per cent, and dental staff
interpreters which rated ‘high’ or ‘very high’ by 31 per
cent of respondents. The most unsatisfactory methods
of communication with a non-English speaking patient
were hand gestures and dictionaries with 30 per cent of
respondents rating these methods as ‘highly
unsatisfactory’ or ‘unsatisfactory’. If a respondent had
no experience in a particular method of communication,
there was the option of indicating ‘non-applicable’ to
that method. The highest rate of ‘non-applicable’ was
for professional telephone interpreters, reported by 70
per cent of respondents, followed by chairside
professional interpreters with 56 per cent.
Alternative methods of communication were
reportedly used by 79 per cent of respondents. The
most common alternative communication methods
were diagrams, models, intra-oral cameras, diagnostic
imaging and mirrors.
Australian Dental Journal 2005;50:4.

Issues concerning communication difficulties in the
dental setting
Respondents indicated endodontics (listed by 28 per
cent) and periodontics (19 per cent) as the disciplines
which presented the most difficulty in explanation to a
patient who did not speak English. A number also
noted concerns regarding treatment planning (18 per
cent) and medical/dental history (15 per cent). The
percentage of respondents who had referred a patient
to another dentist on the grounds of language was 15
per cent. Informed consent was reportedly
compromised by 29 per cent of respondents as a result
of language barriers, and potentially compromised by a
further 7 per cent. Seventy-eight per cent of
respondents believed the level of training provided to
dentists to prepare them for treating patients who have
limited English was ‘poor’ or ‘very poor’.
Reasons for difficulties with specific languages
The major themes arising from responses to this
question were common to many languages. Such
themes included problems with new migrants who have
poor language skills, patients who have children able to
interpret so the patient does not have to become
proficient in English, and a lack of knowledge of
customs and culture associated with a language, which
makes communication difficult. This last theme was
particularly associated with patients who speak Asian
languages.
Problems and advantages with professional
interpreters
Problems with professional interpreters
The major themes arising from responses to this
question on problems with professional interpreters
included time, cost increase and practicality. The
following respondent’s quote exemplifies these
opinions which were shared by many respondents: ‘I
have experienced professional problems due to the high
cost of professional interpreters. They should be
trained and government funded.’ Many respondents
also questioned the ability of the interpreter, especially
if the interpreter is not specifically trained in dental
terminology.
Advantages with using professional interpreters
The major themes arising from responses to this
question on the advantages of professional interpreters
included interpreter speed, accuracy and clinician
confidence in communication. These results are
summarized by the following quote by one respondent:
‘Professional interpreters have been successful and have
clear explanations, providing better informed consent.’
Problems and advantages with informal interpreters
Problems with informal interpreters
The major disadvantages with informal interpreters
were similar to those for professional interpreters.
Interpreter ability was frequently quoted as being a
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problem. Respondents were concerned with the
informal interpreter’s accuracy of translation, grasp of
dental terminology, and proficiency in both English and
the other language. Another issue raised was the
increase in appointment time caused by the interpreter.
Other comments related to problems with using an
informal interpreter included concern for the patient’s
privacy, and how embarrassment in discussing personal
details (including cost of treatment) causes the patient
not to reveal complete or accurate information through
the informal interpreter. There was also concern
regarding the use of children to translate, particularly
in relation to the child’s comprehension of dental
terminology, understanding of disease and resulting
compromise of patient privacy. A minority of
respondents recognized the potential legal issues
associated with the use of an untrained interpreter.
Advantages with using informal interpreters
The major themes arising from responses to this
question included: convenience, as most clinicians
appreciated the fact that informal interpreters were
readily available; speed of translation and lack of
expense. Many respondents perceived informal
interpreters as a valuable means of gaining patient
trust. Some simply appreciated that ‘informal
interpreters work’ and ‘provide the ability to get by’.
Costs related to treating patients with communication
difficulties
The attitudes evident from responses to this question
varied greatly. Respondents’ attitudes ranged from ‘no
increase in time or cost of treating patients’ to
‘substantial increases in time and cost’. For those who
indicated an increase in time and costs, the reasons for
such can be grouped into the following themes: (1) time
in treating patient; (2) time in administration; and (3)
direct increases in costs.
Firstly, most respondents reported increased
appointment time when treating a patient who does not
speak English. Many said that no extra charge was
applied for the increased appointment length and, as
such, efficiency and profitability were decreased. The
increase in appointment time stemmed from continual
repetition of statements, both through an interpreter
and without an interpreter.
Secondly, administration time and costs were
reportedly increased because of time taken arranging
interpreters. It was also reported that patients often
missed appointments due to a communication
breakdown, necessitating re-appointment which
required additional time.
Finally, direct increases in costs were reportedly
caused by staff costs (if the staff member was required
to leave normal duties to facilitate interpretation),
interpreter costs and decreased revenue. Several
respondents reported that the inability to explain
complex treatment plans often resulted in the provision
of simpler treatment options.
237

Usefulness of dental health publications
Approximately half the dentists surveyed had access
to dental health publications in languages other than
English and 80 per cent of respondents indicated that
they felt dental health publications were useful in the
provision of dental services to patients.
An issue raised by a number of respondents was that
the publications are useful as long as the patient can
read. Several respondents recognized that the
pamphlets should not replace adequate verbal
communication but may supplement communication
especially for post-operative instructions and
education. Respondents indicated that publications
should be inexpensive and easy to store. A few
respondents required publications in Aboriginal
languages.
Informed consent as related to language difficulties
Informed consent was reportedly compromised due
to language barriers by 29 per cent of respondents and
potentially compromised by a further 7 per cent.
Common themes arising from responses that indicated
informed consent had been compromised included the
dentist admitting having accepted implied consent from
the patient, recognizing that the patient would
probably ask more questions if they could speak
English, and that treatment options cannot be fully
explained, causing potentially less than ideal treatment
being offered. This was exemplified by the following
response: ‘I feel the patient would ask more questions if
they could without going through an interpreter.
Because of the language barrier I believe the patient
accepts the treatment without questioning.’ This
attitude was shared by another respondent, who also
recognized the effect of the patients’ culture on their
perception of dental treatment: ‘Yes, informed consent
has been compromised – patients don’t understand why
they are being questioned on seemingly non-related
problems. Often they come from places where no one
worries about lawyers.’
As for respondents who reported that consent was
never compromised, most stated that no treatment was
performed unless they were sure the patient had
understood and if this was uncertain, the patient was
required to bring an interpreter to the next visit. Such
principles were illustrated by the following quote: ‘No
compromise – we have strict guidelines: no informed
consent – no treatment, even if the patient has to wait
in pain until consent can be given properly.’
Recommendations
These are listed in table form in the Conclusion.
Comments from respondents regarding
recommendations for the patient include: ‘Non-English
speaking patients should see a dentist who speaks their
language as this helps both parties in the treatment
process.’ Another felt that ‘patients need to be more
responsible for their own needs and organize an
interpreter for themselves’.
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In regards to recommendations for the clinician, the
following quotes illustrate common themes: ‘Teach
dentists better communication all round with English
and non-English speaking patients’ and ‘It is very much
up to the dentist to ensure that information is provided
to and understood by the patient.’
In reference to action that the governing bodies of
dentistry can take to improve communication, one
particularly irate respondent recommended: ‘We need
government funded interpreters, trained in
medical/dental . . . they should have facilities and not
burden health professionals and compromise our level
of care.’ The results provide evidence of a range of
attitudes and a number of significant issues.
DISCUSSION
Given the significant percentage of the Western
Australian population who do not speak English
(Australian Bureau of Statistics (ABS) data indicate that
English is spoken at home by only 84 per cent of the
WA population),11 it is important that dentists
recognize the bearing that language barriers have on
patient treatment. Generally, migrants may be
disadvantaged in terms of their health and/or access to
services. Specifically, language barriers appear to be a
disadvantage in accessing satisfactory care and in
particular preventive care.3,4
This study found that a majority of respondents
encounter patients with language barriers which cause
communication difficulties and interfere with care, a
similar finding to that of other studies.1,8,12 However,
15 per cent of respondents reported never encountering
patients with language barriers. This may be due to the
location of the practice – in an area with little ethnic
migration – or it is possible that this indicates the
respondents fail to realize or acknowledge that a
patient has limited or no English skills.
Means of interpretation
The use of interpreters is the standard solution to
language barriers.6 According to the results of this
study, the employment of professional chairside
interpreters in the dental setting is relatively rare.
Despite this, dentists with access to professional
interpreters have reported high satisfaction and a very
low level of dissatisfaction with this method. Similar
studies accord with these results.8,13 Despite the
necessity for professional interpretation, respondents
rely primarily on informal interpreters and staff
interpreters.
Professional interpreters are the only interpreters
with the potential to maintain the patients privacy and
facilitate interpretation in both languages with
associated knowledge of medical/dental terminology.13,14
In cases where language is compromised, the clinician
should involve competent bilingual adult interpreters.1
Medical literature reveals that untrained interpreters
may be biased,15 and the patient sacrifices privacy and
may suffer embarrassment.6,14 There may also be
Australian Dental Journal 2005;50:4.

concerns regarding the English proficiency of the
interpreter.10 Despite the shortcomings, the frequent use
of informal interpreters may be considered a positive
step in the management of non-English speaking
patients as it indicates recognition of the language
barriers and demonstrates an attempt to overcome
them.
Respondents reported utilizing children in the
interpretation process. It is generally inappropriate to
use children as interpreters as the child may not be
aware of the correct translation, and have little
understanding of the symptoms referred to.16 These
issues were recognized by several respondents. There
should also be concern regarding the altered nature of
family dynamics when children are placed in the role of
interpreter for an older family member.6,17
Using in-house (dental staff) interpretation may
provide fast and convenient access to interpretation, in
association with knowledge of dental terminology and
concepts, and this method of communication was
favourably reported by respondents who had access to
it. However, the staff member is generally untrained in
interpretation, and interpretation is not usually part of
the job description, and may interrupt their regular
duties. It may also be difficult for the staff interpreter to
be objective.10
Telephone interpreters are increasingly used in
medical clinics to communicate with patients who do
not speak the same language as the physician. The
service is available to WA dentists at less cost than that
for chairside interpreters, yet this service is reportedly
used very little. Dentists appear to be either ignorant of
the telephone communication services available, or
would always prefer to use another method of
communication, such as informal interpreters. There is
understandably a low tolerance by dental professionals
of interpretation methods which increase appointment
time or costs.8 Professional/telephonic interpreters may
be considered a second choice for interpretation if there
is a multilingual staff member or informal interpreter
available, however inappropriate this may be.
The Western Australian Government Department of
Immigration provides access to professional interpreter
services for medical and dental clinics. However, unlike
medical clinics, dental practices do not have government
funding for services. The current cost of the interpreter
service (A$141.05 for 90 minutes) is likely to be the
most significant deciding factor when a dentist chooses
not to use a professional interpreter. Accessibility to the
service is a further issue as the interpreter needs to be
booked at least 48 hours in advance. Telephone
interpretation is less expensive, starting at A$21.70 for
a 15 minute session. As there is ubiquitous availability
of telephone interpretation services, this method of
communication may be particularly important for
regional and remote dental services.
Costs
The majority of respondents reported an increase in
time taken for appointments, especially for initial
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appointments when the medical/dental history,
examination and treatment planing discussion occur.
Administration time is increased and the direct increase
in the costs to the dental practice occurred as the
appointment time was increased but the patient is
usually not charged an extra amount. There is also the
cost of interpreting services which should be the
liability of the patient. Respondents reported that
treatment plans may have to be simplified due to an
inability to explain complex treatment. This impacts
not only on revenue, but also on the quality of patient
care.
Dental health publications
Despite the use of multilingual literature and
pamphlets in the dental clinic being the most commonly
suggested means for improving communication, only a
minority of clinicians have access to the literature. The
reasons given included cost, accessibility, language
availability (particularly Aboriginal) and a lack of
knowledge of where to obtain the publications.
Respondents often cited using the pamphlets for post-
operative instructions. However, the use of written
materials assumes a certain level of literacy of the
patient and the pamphlets are not a substitute for an
interpreter or good verbal communication.
The popularity of the publications makes further
investigation necessary into the source of the literature,
target language groups and cost.
Informed consent
Direct verbal communication between a dentist and a
non-English speaking patient may not be adequate
unless a professional interpreter is present, and consent
obtained across a language barrier without competent
interpretation is unlikely to be truly informed.6 Failure
to communicate adequately was determined to be the
source of negligence in several relevant US law cases.6
In the present study, nearly 60 per cent of respondents
reported that they did not use professional interpreters,
raising the ethical and legal issues of using other
methods of interpretation including the dentist’s own
inadequate language skills.8
The comments of some respondents indicated a level
of disregard for the legal implications of informed
consent. In situations where there is doubt as to the
level of patient understanding, the involvement of
competent interpreters is essential.1
Dental disciplines and terminology
The dental disciplines most frequently associated
with difficulty in communication were endodontics and
periodontics. Similar results were reported by other
studies.1,12 Communication difficulties in relation to
preventive care was also reported in other studies
although it did not feature in the current study. It is
difficult to explain the complex and abstract concepts
of periodontics and endodontics when communication
is limited to hand gestures and diagrams. For example,
239

attempts to explain ‘calculus, bacteria and toxins’
prove futile as does describing the ‘type of pain’ in
endodontic diagnosis. Some respondents described
difficulty in relating these concepts even to patients
with whom there is no additional language barrier.
Results of this study suggest that less complicated
treatment may be offered to patients on the basis of an
inability to explain more complex treatment. This may
compromise the best interests of the patient if such less
complicated treatment is also less appropriate.1
There were also concerns regarding medical and
dental history taking. Medical literature suggests that
language barriers may be somewhat overcome with the
use of standardized history forms in languages other
than English although these would not be expected to
replace an interpreter and verbal communication.14
Recommendations
Many respondents indicated frustration with the
current measures available for communicating with
patients who do not speak English. A frequently
presented issue was the lack of accessibility and high
cost of professional interpretation services leading
many respondents to consider their use impractical.
Regardless, the use of professional interpreters – either
chairside or telephonic – is the preferential and
foremost method of communication required by
clinicians treating a patient with limited English
language ability.
In treating patients with whom there are
communication difficulties, yet verbal communication
is possible, non-verbal adjuncts may be used to
supplement communication. The issue is to decide
when a patient’s language skills are sufficiently high to
provide a level of understanding that permits informed
consent.5
In light of this survey, the recommendations listed in
Tables 1, 2 and 3 have been formulated to provide
means to improve dentist-patient communication in the
multilingual dental setting in relation to both clinical
procedures and dental health planning.
Table 1. Suggestions for action the dentist may take
1. Recognize a situation where communication will be compromised
1. due to a language barrier
2. Know how and where to access interpreter services
3. Utilize alternative methods of communication, for example,
diagrams/drawings, models, radiographs and intra-oral cameras
to complement verbal communication
4. Provide the patient with written information in the patient’s
language
5. Undertake language courses of languages frequent to the area of
practise
6. Refer patients to a dentist who speaks the same language as the
patient
7. Take extra time with the patient
Table 2. Suggestions for action the patient may take
1. Inform the dental clinic prior to the appointment that the patient
1. does not speak English
2. Organize interpreters themselves
3. Learn English
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Table 3. Suggestions for action the governing bodies
of dentistry may take
1. Inform dentists of interpretation services and improve availability
1. with funding
2. Produce and distribute a register of dentists who are multilingual
3. Provide better dental public health information for immigrants
4. Improve undergraduate training in the provision of dental
services to immigrants, both linguistic and cultural
Limitations and further research
This study surveyed one half of the dentist-patient
relationship. It would be expected that patients have
differing concerns and priorities regarding dental
communication, and further research is required to
elicit the patients’ opinions and recommendations for
improving dentist-patient communication.
The high percentage of respondents who speak a
language other than English suggests that this group
may be over-represented in the sample. This may be due
to personal experiences of communication difficulties
and hence an increased interest in the subject of this
study.
The lack of response may be because recipients did
not consider the topic to be a significant issue in their
practice. Given the localized distribution of non-
English speaking people in Western Australia, it is
likely that some practices will have very few patients
who do not speak English. However, this study has
demonstrated that many practices do encounter non-
English speaking patients regularly.
ACKNOWLEDGEMENTS
The authors would like to thank all dentists who
took part in this study: Dr John Davies, Dr Peter
McKerracher and the WA branch of the ADA. This
study was supported by the Australian Dental Research
Foundation, Undergraduate Summer Vacation
Research Grant 2003-2004.
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Address for correspondence/reprints:
Dr Linda Slack-Smith
Senior Lecturer in Oral Epidemiology
School of Dentistry
The University of Western Australia
35 Stirling Highway
Nedlands, Western Australia 6009
Email: lindas@cyllene.uwa.edu.au
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