A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures

Paul O'Dwyer; Viveka Guzman; Emma Wallace; Frank Doyle

doi:10.12688/hrbopenres.13373.2

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Study Protocol

Revised

A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures

[version 2; peer review: 2 approved]

Paul O'Dwyer¹, Viveka Guzman¹, Emma Wallace², Frank Doyle³

PUBLISHED 03 Mar 2025

Author details Author details

¹ Structured Population and Health-services Research Education PhD Programme, Royal College of Surgeons in Ireland, Dublin, Ireland
² Department of General Practice, Royal College of Surgeons in Ireland, University of Medicine & Health Sciences, Dublin, Ireland
³ Department of Health Psychology, Division of Population Health Services, Royal College of Surgeons in Ireland, University of Medicine & Health Sciences, Dublin, Ireland

Paul O'Dwyer
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Viveka Guzman
Roles: Data Curation, Formal Analysis, Investigation, Project Administration

Emma Wallace
Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration

Frank Doyle
Roles: Conceptualization, Methodology, Supervision

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Introduction

Dental operative procedures, by their interventive nature, impede the opportunity for peri-intervention verbal communication between patients and clinicians. This can impair trust, consent, and shared decision making with the potential of adversely affecting patient dignity, and potentially resulting in suboptimal clinical outcomes.

This scoping review aims to interrogate the literature concerning non-verbal communication methods used in dental and medical practices during peri-interventive procedures, in aiding communication between clinician and patient. We will also ascertain how these align with the Limited Capacity Model of Motivated Mediated Message Processing (LC4MP) communication theory.

Methods

The framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews, will be used to guide this scoping review and reporting methodology. Selected electronic databases (Medline, Embase, Cochrane Library and Scopus), PsychInfo, CINAHL and grey literature sources will be searched.

Inclusion criteria are: articles written in the English language, publications between 2000 and 2025, peer-reviewed empirical studies, with either qualitative or quantitative data, mixed methods, reviews, book chapters and grey literature with a principal focus on non-verbal communication in the healthcare setting.

A narrative synthesis will be conducted, with results reported according to elements of LCM4P theory: cognitive load, motivated messaging, message processing and memory.

Conclusion

This scoping review will contribute to our methodological and theoretical understanding of the use of non-verbal communication strategies in clinical settings.

Keywords

nonverbal, dental, communication, patient

Corresponding author: Paul O'Dwyer

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2025 O'Dwyer P et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: O'Dwyer P, Guzman V, Wallace E and Doyle F. A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures [version 2; peer review: 2 approved]. HRB Open Res 2025, 5:49 (https://doi.org/10.12688/hrbopenres.13373.2) First published: 07 Jul 2022, 5:49 (https://doi.org/10.12688/hrbopenres.13373.1) Latest published: 03 Mar 2025, 5:49 (https://doi.org/10.12688/hrbopenres.13373.2)

Revised Amendments from Version 1

This updated version includes definitions of per-interventive procedures and nonverbal communication. We have aligned the protocol with the Arksey & O’Malley (2005) for our methodology. We have matched the aims and objectives to reflect the research question. We have also further elucidated on the search terms and methodology. We have provided a rationale on the date limitation for the review. We have amended and increased the references to reflect these various changes. Further, we have amended the timeframe for this review to update to 2025.

See the authors' detailed response to the review by Esther Lydie Wanko Keutchafo
See the authors' detailed response to the review by Abukari Kwame

Introduction

Dental operative procedures, by their interventive nature, impede the opportunity for peri-intervention verbal communication between patients and clinicians. Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural perpartion until full recovery¹. While good communication is enshrined in policy², expected in clinical standards³, and advocated as best practice⁴, there is a risk that such impaired communication could erode or impair trust, consent, shared decision making and adversely impact on patient dignity and clinical outcomes⁵. Therefore, a focus on enhancing peri-interventive communication could be beneficial for patients, clinicians and the healthcare system.

Internationally, a recent adult Dental Health Survey in the United Kingdom (UK) reported that 11% of patients complained of “…not being involved in decisions about dental care or treatment”⁶. Patients felt less satisfied with their involvement in decision making for treatment planning and this impacted on their clinical outcomes. Elsewhere in the literature, certain key areas need to be addressed for study which include intra-operative communication and active involvement of the patient⁷. Active intra-operative communication would include feedback from the operator/clinician. Poor interpersonal communication was identified as the most common barrier to adherence with dental treatment for female caregivers of children in a study in the United States (US)⁸. The literature also advocates increasing focus on communication skills in dental students, as an integral part of undergraduate curricula⁹. In Jamaica, Jamaican Sign Language has been made compulsory in the education of dental auxiliaries to reduce barriers to attendance for the deaf community and to safeguard dignity and consent in that jurisdiction¹⁰.

Suboptimal clinical outcomes in dentistry can lead to litigation¹¹. Barriers to effective communication, particularly during intervention, have been identified by the medical indemnifier (Medical Protection Society) as a leading cause of litigation with the majority of negligence cases not related to the clinical quality of care but rather triggered by inadequate communication¹². This was underlined by the subsequent UK National Health Service publication “Much More Than Words”, which advocates non-verbal communication as a useful tool in patient communication¹³. This is further supported by a US national Dentist-Patient survey, which reports “...routine use of all of the communication techniques is low among dentists, including some techniques thought to be most effective with patients with low literacy skills”. These techniques included non-verbal communication with patients (such as hand-signalling or maintaining eye-contact)¹⁴. Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance and paralanguage¹⁵.

Communication theory can guide and optimise communication strategies¹⁶. It is argued that communication theories should accomplish three goals: (i) be inclusive of a wide range of phenomena; (ii) strive for explanatory and predictive power; and (iii) strive for practical utility in real-world communication scenarios¹⁷. One such theory is the Limited Capacity Model of Motivated Mediated Message Processing (LC4MP)¹⁸. This theory attempts to elucidate understanding of the dynamic interactions between mediated messages and the human information processing system, particularly in the healthcare setting. It provides a theoretical and methodological framework to investigate an individual’s interaction with communication phenomena in real time. LC4MP captures the following three domains: cognitive load (how the limited capacity human information processing system is impacted by message characteristics) motivated messaging (multidimensional emotional responses to message processing) and memory. This theory can provide a structure to appraise the communication strategies and highlight any pertinent gaps. LC4MP has been extensively used in research for medical messaging regarding behavioural modification, e.g. smoking cessation¹⁹. This theory will be used in this research to support a robust investigation of real-time patient interaction and the effects of using a nonverbal communication system.

To date, no review of non-verbal clinical interactions has been conducted using this theory. This scoping review aims to interrogate the literature concerning nonverbal communication methods used in dental and medical practices during peri-interventive procdures, in aiding communication between clinician and patient. We will also align these with the Limited Capacity Model of Motivated Mediated Message Processing (LC4MP) communication theory. Specifically, we will:

(1) Identify the use of non-verbal communication systems in dental and medical clinical settings
(2) Ascertain reported communication difficulties and facilitators in peri-interventive procedures in dental and medical settings
(3) Determine the theoretical underpinnings of reported non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome measures.

Ultimately, the findings will inform intervention development for non-verbal peri-intervention communication strategy in dentistry.

Methods

Scoping review framework

This scoping review will follow the framework proposed by the Joanna Briggs Institute (JBI)²⁰. This protocol follows the Arksey & O’Malley^21,22 methodological recommendations, with the exception of the optional consultation stage. While the overall conduct of the scoping review is informed by the JBI framework, the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR)²³ will be used to guide the reporting of the scoping review.

Stage 1: Identifying the research question

Overarching question: What non-verbal methods of communication currently exist/are used in dental/medical clinical settings in both primary and secondary care, what are the theoretical underpinnings of these communication methods, and what methods are used to evaluate these communication methods?

Stage 2: Identifying the relevant studies

Table 1. Eligibility criteria for scoping review.

Inclusion criteria			Exclusion Criteria
Population	Concept	Context	Population	Concept	Context
>18 Years	Non-Verbal Communication	Clinical Setting	<18 Years	Verbal Communication	Non Clinical Setting

Search strategy

The search strategy will identify both published and grey literature and will follow a three-step strategy, as per JBI.

The first step is a limited search. This will include the searching of two appropriate online databases, in this case Medline and Embase. Analysis will then be conducted on the titles and abstracts of retrieved papers. An analysis will also be undertaken of the index terms used to describe the articles The data extracted will be represented in a tabular and descriptive format that aligns with the review’s objective.

The second step will use all identified key words and index terms to perform a second search (PO’D and VG) of the following databases: Medline, Embase, Cochrane Library, Scopus, PsycInfo, and CINAHL to identify peer reviewed research papers relevant to our aim. This step will be conducted in collaboration with an information specialist.

The third step will be to use reference lists of included articles to search for additional sources.

The grey literature search will be completed by searching ‘Open Grey’ using a similar methodology as above.

The final included studies will be stored and combined using a reference management software package (EndNote) and duplicates will be removed.

Stage 3: Study selection

Titles and abstracts will be screened (PO’D and VG) for inclusion against the inclusion criteria for the review (Table 1). Full text articles of those that appear to meet the inclusion criteria will then be retrieved and screened against the inclusion criteria. For articles that cannot be retrieved, we will contact the authors directly. Those articles that fulfil all the inclusion criteria will be included in the review. At this stage we will also use the ‘cited by’ function in Google Scholar to obtain other relevant articles.

Two reviewers (PO’D, VG) will initially work independently and then come together to compare results. Any discrepancies will be resolved by consensus and if consensus is not reached then they will be referred to a third reviewer (FD).

Studies that do not meet the inclusion criteria will be excluded. Reasons for the exclusion will be provided in an Appendix in the final draft featuring a flow diagram. These will be grouped according to common reasons for exclusion.

The final search results will be displayed in a PRISMA flow diagram, alongside a narrative description of the process.

Stage 4: Charting the data

This scoping review is designed to identify the range of evidence available and represent this as a mapping of the identified data, without the act of synthesis or with particular reference to methodological quality of relevant studies²⁴.

For this scoping review data extraction will adapt the standardised template from the JBI methodology guidance for scoping reviews.

Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of congnitive load, motivation or memory, the components of LC4MP will be specifically extracted from the included studies and included in tabular form as part of the overall results.

Stage 5: Collating, summarising and reporting of results

Results will be reported using the PRISMA-SCR guidelines. Each research question will be reported and presented in a tabular form and as a narrative summary. This narrative description will be used to synthesise the study findings based on themes that are generated from the extracted data, using the LCM4P framework to further delineate results.

Discussion

This scoping review will be the first to utilise communication theory to provide a structure and overview of the literature of non-verbal peri-interventive communication in dental and medical practice. This can contribute to the evidence base to support the use of non-verbal communication by healthcare professionals and patients to benefit patient care. The findings of this scoping review will inform future research on the evaluation and implementation of non-verbal communication in clinical settings.

Dissemination

We intend to disseminate the results through publication in a peer-reviewed journal and conference presentations.

Study status

The study is about to commence, with expected completion by December 2025.

Ethics statement

Ethical approval is not required for this scoping review.

Data availability

No data are associated with this article.

Appendix A

MESH terms used:

((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Faculty Opinions recommended

References

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Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 07 Jul 2022

Author details Author details

Viveka Guzman
Roles: Data Curation, Formal Analysis, Investigation, Project Administration

Emma Wallace
Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration

Frank Doyle
Roles: Conceptualization, Methodology, Supervision

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

Revised

Published: 03 Mar 2025, 5:49

https://doi.org/10.12688/hrbopenres.13373.2

version 1

Published: 07 Jul 2022, 5:49

https://doi.org/10.12688/hrbopenres.13373.1

© 2025 O'Dwyer P et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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O'Dwyer P, Guzman V, Wallace E and Doyle F. A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures [version 2; peer review: 2 approved]. HRB Open Res 2025, 5:49 (https://doi.org/10.12688/hrbopenres.13373.2)

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Open Peer Review

Version 2

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Reviewer Report 18 Mar 2025

Esther Lydie Wanko Keutchafo, University of KwaZulu-Natal, Durban, South Africa

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https://doi.org/10.21956/hrbopenres.15477.r46270

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Reviewer Report 06 Mar 2025

Abukari Kwame, University of Saskatchewan, Saskatoon, Canada

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https://doi.org/10.21956/hrbopenres.15477.r46269

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Reviewer Report 28 Nov 2023

Esther Lydie Wanko Keutchafo, University of KwaZulu-Natal, Durban, South Africa

Approved with Reservations

https://doi.org/10.21956/hrbopenres.14566.r34284

This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Non-verbal communication, clinical nursing care

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 03 Mar 2025

Paul O Dwyer, Royal College of Surgeons in Ireland, Ireland

03 Mar 2025

Author Response
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript ... Continue reading
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: NIL Close
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COMMENTS ON THIS REPORT

Author Response 03 Mar 2025

Paul O Dwyer, Royal College of Surgeons in Ireland, Ireland

03 Mar 2025

Author Response
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript ... Continue reading
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: NIL Close
Report a concern

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Reviewer Report 15 Jun 2023

Abukari Kwame, University of Saskatchewan, Saskatoon, Canada

Approved with Reservations

https://doi.org/10.21956/hrbopenres.14566.r34286

Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures”

This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved.

A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.

Background Section

Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.

Methodology Section

Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)¹.
Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

References

1. Ho IK, Sheldon TA, Botelho E: Medical mistrust among women with intersecting marginalized identities: a scoping review.Ethn Health. 2022; 27 (8): 1733-1751 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Health communication, patient-provider interactions, medical anthropology, language acquisition, qualitative research methods, and Indigenous research methodology

CITE

Report a concern

Author Response 03 Mar 2025

Paul O Dwyer, Royal College of Surgeons in Ireland, Ireland

03 Mar 2025

Author Response
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript ... Continue reading
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: NIL Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 03 Mar 2025

Paul O Dwyer, Royal College of Surgeons in Ireland, Ireland

03 Mar 2025

Author Response
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript ... Continue reading
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable
PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: NIL Close
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Version 2

VERSION 2 PUBLISHED 07 Jul 2022

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Version 2 (revision) 03 Mar 25	read	read
Version 1 07 Jul 22	read	read

Abukari Kwame, University of Saskatchewan, Saskatoon, Canada
Esther Lydie Wanko Keutchafo, University of KwaZulu-Natal, Durban, South Africa

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Reviewer Report

11 Views

18 Mar 2025 | for Version 2

Esther Lydie Wanko Keutchafo, University of KwaZulu-Natal, Durban, South Africa

11 Views Cite this report Responses(0)

Approved

Thank you for satisfactorily addressing all my comments. The manuscript is greatly improved.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

16 Views

06 Mar 2025 | for Version 2

Abukari Kwame, University of Saskatchewan, Saskatoon, Canada

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Approved

I have read the manuscript and found that the authors successfully implemented my suggestions.
They have also addressed all the comments satisfactorily.
I have no further comments.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

37 Views

28 Nov 2023 | for Version 1

Esther Lydie Wanko Keutchafo, University of KwaZulu-Natal, Durban, South Africa

37 Views Cite this report Responses(1)

Approved With Reservations

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Non-verbal communication, clinical nursing care

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Author Response

03 Mar 2025

Paul O Dwyer, Royal College of Surgeons in Ireland, Ireland

PEER REVIEW Responses to Scoping Protocol
REVIEW 1
APPROVED WITH RESERVATIONS
info_outline
Review of “A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures” This manuscript is a scoping review protocol that outlines and justifies the process to be undertaken to scope and review the literature on non-verbal communication strategies used in peri-interventive dental and medical procedures. The protocol outlines the research questions to be explored, the methodology to be employed, and the possible outcomes to be achieved. A detailed background section has been provided to outline a significant gap in the literature and to justify why the intended review is warranted. Furthermore, a clear step-by-step methodology has been provided on how the review will be conducted. However, a few issues must be addressed before the protocol can be indexed. I recommend that the protocol may be accepted for indexing after the following issues are addressed.
We thank the reviewer for the overall positive appraisal.
Background Section
1. Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.
Peri-interventive clinical interactions/interventive procedures are provided with/without the use of local anaesthetic (e.g. restorative procedure in dentistry). For interventive dental procedures, where the patient’s mouth is full (with instruments), there is a risk of impaired communication and potential erosion of trust, consent and shared decision making – as verbal communication can be challenged or absent completely. We have now included this definition in the protocol:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery (1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.”
Methodology Section
1. Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)
Thank you for this recommendation. The scoping review protocol does now adhere to framework methodology of Arksey and O’Malley (21) including the following stages: identifying the research question (Page 4); identifying relevant studies (Page 5); study selection (Page 6); charting the data; and collating, summarizing, and reporting the results (Page 7) . Arksey and O’Malley do suggest an Optional Consultation 6^th Stage. This is not included here.
To enhance clarity, we have added the following to the protocol:
“This protocol follows the Arksey & O’Malley (21) methodological recommendations, with the exception of the optional consultation stage.”

2. Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
The second stage for the framework methodology as outlined by Arksey (21) involves the search strategy via identifying relevant studies. We have now included examples of the search terms within the methods, and a comprehensive list of exact terms and combination in Appendix A.

3. Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Thank you for spotting this error. Reviews will not be included and the abstract has been amended to reflect this change.

4. Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Preliminary literature searches could not find any relevant data before this date and so we decided to formally review the literature from 2000 onwards.

5. Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
We will not be conducting a thematic analysis per se, so this has been modified. We have clarified the procedure as follows:
“Data extracted here will be subdivided into categories: author, year, setting, aim, sample description and size, study design, description of intervention (including elements of LC4MP: cognitive load, motivation and memory), outcome measures and main results. Any statements or elements pertaining to the authors consideration of cognitive load, motivation or memory, the components of LC4MP, will be specifically extracted from the included studies and included in tabular form as part of the overall results.”

6. Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.
Thank you for this suggestion. The proposed Stage 6 consultation exercise in the framework is optional (21). This process is not considered as part of the PRIMSA-ScR (23) recommendation and we have decided not to include it in this review.

· Is the rationale for, and objectives of, the study clearly described?
Yes
· Is the study design appropriate for the research question?
Yes
· Are sufficient details of the methods provided to allow replication by others?
Yes
· Are the datasets clearly presented in a useable and accessible format?
Not applicable

REVIEW 2
APPROVED WITH RESERVATIONS
This manuscript is a scoping review protocol on non-verbal communication strategies used in peri-interventive dental and medical procedures. A background section has been provided to justify why the intended review is warranted. Furthermore, a step-by-step methodology has been provided on how the review will be conducted.

However, the following issues must be addressed:

1. The authors must define peri-interventive dental and medical procedures as well as non-verbal communication in the background section.

We have now provided the following definitions in the Background:
“Peri-interventive procedures are defined as patient-centred, multidisciplinary and integrated medical care for patients from the onset of procedural preparation until full recovery”(1). Verbal communication can be challenged or absent completely while the patient’s mouth is treated with instruments which exacerbates the risk of impaired communication and potential erosion of trust, consent, and shared decision making. In this context, non-verbal communication is a viable option to alleviate these issues.
“Nonverbal communication is defined as nonlinguistic, informative aspects of behaviour and appearance, including head and body features or movements, touch, interpersonal distance, and paralanguage (4).”

2. The authors outlined their specific aims which do not correspond to their questions nor objectives. How will they achieve those aims? Please match the research questions and objectives to your specific aims.

The aims here are to ascertain the level to which non-verbal communication currently exists within the peri-operative visit. By conducting this scoping review, the literature will be interrogated to examine this. We have now modified and aligned the Research Question with the Aim and Objectives. We provide the following table here to illustrate the alignment, and have made the relevant adjustments in the document:

Research question
Aim
Objectives

Stage 1: Identifying the research question
Overarching question: What non-verbal methods of communication
currently exist/are used in dental/medical clinical
settings in both primary and secondary care, what are the theoretical
underpinnings of these communication methods, and what
methods are used to evaluate these communication methods?
Abstract

This scoping review aims to interrogate the literature concerning nonverbal
communication methods used in dental and medical practices
during peri-interventive procedures, in aiding communication
between clinician and patient. We will also ascertain how these align
with the Limited Capacity Model of Motivated Mediated Message
Processing (LC4MP) communication theory.

(1) Identify the use of non-verbal communication systems
in dental and medical clinical settings
(2) Ascertain reported communication difficulties and
facilitators in peri-interventive procedures in dental
and medical settings
(3) Determine the theoretical underpinnings of reported
non-verbal interventions, according to LC4MP theory
(4) Identify typical methodological aspects, such as outcome
measures.

3. The table of eligibility criteria must include one column for inclusion criteria and one for exclusion with some examples based on the PCC (Population, Concept, Context) framework if it is the PCC framework you are used to frame your research question. As such, the table presented does not inform us about the criteria.

The table is now amended to reflect this.
Table 2: Eligibility criteria

Inclusion Criteria
Exclusion Criteria

Population
Concept
Context
Population
Concept
Context

>18 Years
Non-Verbal Communication
Clinical Setting
<18 Years
Verbal Communication
Non Clinical Setting

4. Please provide a rationale for language limitation as well as date limitation in the methodology, especially because you stated in the abstract that it will be articles in English from 2000 to 2020 when we are already in 2023.

Please see response above for the rationale for excluding literature pre-2000. The investigators have no resources to examine non-English articles. We will now update the search to include literature to 2025.

5. Did you conduct a preliminary search to identify the possibility of finding relevant articles? If yes, what keywords or Mesh terms did you use to search for articles? If no, please provide a table of a preliminary search with keywords used, filters, results, and time. This is to ascertain that you won't conduct a review that will yield no result.

Yes – a preliminary search was conducted. This preliminary search utilised key terms nonverbal communication, sign language , communication barriers and perioperative care. This yielded some promising literature and we decided to proceed.

This was the MESH search used:
((((((nonverbal communication[Title/Abstract]) OR (nonverbal signal[Title/Abstract])) OR (gesture[Title/Abstract])) OR (sign language[Title/Abstract])) OR (communication barriers[Title/Abstract])) OR ("Nonverbal Communication"[Mesh])) OR ("Communication Barriers"[Mesh])) OR ("Sign Language"[Mesh])) AND (("Operating Rooms"[Mesh]) OR ("Perioperative Care"[Mesh])) AND dent*

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable

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Competing Interests

NIL

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Reviewer Report

70 Views

15 Jun 2023 | for Version 1

Abukari Kwame, University of Saskatchewan, Saskatoon, Canada

70 Views Cite this report Responses(1)

Approved With Reservations

Given that the scoping review centers on communication in peri-intervention dental and medical settings, the author/s must explain what peri-interventive procedure/s is/are and why non-verbal communication is crucial in that setting.

Methodology Section

Scoping review framework: Although the author/s made references to standard reporting procedures for a scoping review, the main methodology for any scoping review, based on scholarly consensus, is that of Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework. I wonder why the author/s is/are not following the methodology of scoping review as outlined in Arksey and O’Malley (2005)¹.
Search strategy: What keywords/phrases will be used to search for articles? The author/s must identify and state some keywords to be used when searching databases as part of this protocol.
Study selection: Unless the review is going to be a review of reviews, is it not advisable to include reviews in a scoping review study? The authors mention in the abstract that reviews will be included in the study. Empirical studies and grey literature can be included but not reviews. The findings of reviews can conflate that of primary research results. If the author/s still want/s to include reviews in the proposed scoping review, then they must justify that.
Also, why will the scoping review include only studies published between 2000 and 2022? Any justification for this limitation?
Stage 5: Using the LC4MP theory in the proposed scoping review will be critical and novel. However, will the author/s be including primary studies that utilize the theory? In other words, how will the LC4MP theory guide the analysis of the extracted data from included studies? Also, how will the thematic analysis be undertaken since the author/s indicate/s that themes will be generated from the extracted data?
Stage 6: Arksey and O’Malley (2005) scoping review framework includes stage 6, where authors must engage experts in the specific field of the review to gain further knowledge about the topic under review. This protocol does not say anything about that critical stage in scoping reviews. The author/s must justify why this step will not be implemented in their review.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

References

1. Ho IK, Sheldon TA, Botelho E: Medical mistrust among women with intersecting marginalized identities: a scoping review.Ethn Health. 2022; 27 (8): 1733-1751 PubMed Abstract | Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Health communication, patient-provider interactions, medical anthropology, language acquisition, qualitative research methods, and Indigenous research methodology

Respond to this report

Responses (1)

Author Response

03 Mar 2025

Paul O Dwyer, Royal College of Surgeons in Ireland, Ireland

Is the rationale for, and objectives of, the study clearly described?

Yes

Is the study design appropriate for the research question?

Yes

Are sufficient details of the methods provided to allow replication by others?

Partly

Are the datasets clearly presented in a useable and accessible format?

Not applicable

View more View less

Competing Interests

NIL

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Grocott MP, Mythen MG: Perioperative medicine: the value proposition for anesthesia?: a UK perspective on delivering value from anesthesiology. Anesthesiol Clin. 2015; 33(4): 617–28. PubMed Abstract | Publisher Full Text

[2] 2. Burke S, Barry S, Siersbaek R, et al.: Sláintecare - A ten-year plan to achieve universal healthcare in Ireland. Health Policy. 2018; 122(12): 1278–82. PubMed Abstract | Publisher Full Text

[3] 3. Council GD (UK): Standards for the Dental Team. 2013. Reference Source

[4] 4. Dental Council (Ireland) Code of Practice: Professional behaviour and professional conduct. 2012.

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A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures

Abstract

Introduction

Methods

Conclusion

Keywords

Revised Amendments from Version 1

Introduction

Methods

Scoping review framework

Stage 1: Identifying the research question

Stage 2: Identifying the relevant studies

Table 1. Eligibility criteria for scoping review.

Search strategy

Stage 3: Study selection

Stage 4: Charting the data

Stage 5: Collating, summarising and reporting of results

Discussion

Dissemination

Study status

Ethics statement

Data availability

Appendix A

References

Comments on this article Comments (0)

Open Peer Review

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Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Are you a HRB-funded researcher?

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A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures

Abstract

Introduction

Methods

Conclusion

Keywords

Revised Amendments from Version 1

Introduction

Methods

Scoping review framework

Stage 1: Identifying the research question

Stage 2: Identifying the relevant studies

Table 1. Eligibility criteria for scoping review.

Search strategy

Stage 3: Study selection

Stage 4: Charting the data

Stage 5: Collating, summarising and reporting of results

Discussion

Dissemination

Study status

Ethics statement

Data availability

Appendix A

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Competing Interests Policy

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Are you a HRB-funded researcher?

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