M ANAGING M ALADAPTIVE B EHAVIORS The Use of Dental ... · SOUTHERN A SSOCIATION OF INSTITUTIONAL D ENTISTS — Self-Study Course Module 6 1 M ANAGING M ALADAPTIVE B EHAVIORS The

SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 6

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MANAGING MALADAPTIVE BEHAVIORSThe Use of Dental Restraints and Positioning Devices

Purpose of this ModuleThis module is designed to provide a comprehensive view of dental restraints and positioning devices. The

emphasis is on the treatment of the severely/profoundly developmentally disabled individual, but the informationcould be applied to pediatric, geriatric or psychiatric individuals.

Learning ObjectivesAfter reviewing the written and videotape materials, the participant will be able to:

1. Define the three types of restraints and give examples of each.

2. Describe at least one physical restraint that should not be used with developmentally disabled patients.

3. Describe one type of positioning device.

4. Describe the process for determining the need for restraints and discuss five criteria that may beconsidered in the process.

5. State three areas of law that may apply to restraints.

6. Discuss three elements of informed consent.

7. Contrast the professional community standard with the reasonable patient standard.

8. Document restraint usage.

9. Describe two ethical issues that may be associated with restraint usage.

10. Prepare a comprehensive restraint policy.

11. State at least five issues that should be addressed in staff training on restraints.

12. Describe the infection control procedures that should be used with intraoral restraints.

13. Discuss the psychological effects of restraints on developmentally disabled individuals.

14. State at least four physical injuries that could occur when restraints are employed.

15. Demonstrate or describe the correct application of the Molt® mouth prop, McKesson® bite block,Papoose Board®, and wrist bracelets.


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MANAGING MALADAPTIVE BEHAVIORSThe Use of Dental Restraints and Positioning Devices

INTRODUCTIONIndividuals who are disabled deserve quality

dental services limited only by their ability to benefitfrom and tolerate dental treatment. If maladaptivebehaviors are demonstrated in the dental treatmentenvironment, the behavior must be addressed and thedelivery of care must be managed to meet the per-son's needs. For some patients, less restrictive be-havior modification techniques such as repetition ofinstruction, verbal reinforcement, and visual cues arequite effective (see Module 2). Many of these behav-ior modification techniques are routinely used bymost dentists. However, many of these techniquesare of little value in managing severe maladaptivebehaviors that threaten the safety of the patient anddental staff. To manage these behaviors, dentalpersonnel must resort to more restrictive techniquessuch as restraints, conscious sedation, or generalanesthesia.1 Without these more restrictive manage-ment techniques comprehensive dental services forsome disabled people would be impossible.1,2

The decision to employ these behavior manage-ment techniques is influenced by other concerns inaddition to the patient's dental needs. Rising mal-practice premiums, recent litigation, public percep-tion, and professional guidelines, all affect the tech-niques used to manage maladaptive behaviors.

The information presented in this module is oneapproach to the use of restraints and should not beinterpreted as the standard for all circumstances.Each practitioner must follow the standards andguidelines specific to his/her locality.

PHILOSOPHY OF USEThe goal in dental treatment for the disabled individ-ual is to treat the patient in the safest and most effi-cient manner.3 Thus, restraints used in the dentalenvironment should never be used for the convenience of the dentist and staff, but must beemployed for the protection of the patient.1,4-9 Re-straints are effective in managing unwanted physicalmovements in physically handicapped, in

mentally handicapped, and in psychiatrically im-paired patients who exhibit difficult behavior andwith whom normal communication cannot be estab-lished.10 Restraints should never be used as punish-ment,1,4-16 or as a substitute for psychologic manage-ment of the patient.12 In addition, restraints shouldhave the lowest possible potential to cause physicalinjury,4,9,11,16 should be the least restrictive alterna-tive,4-7,16 and should be used only with informedconsent1,4-7,9,11,17-21 and proper documentation.1,4-7,9,17,21

Dental restraints are temporary and specificallylimited to the provision of dental care and are notanalogous to general behavioral restraints.1

DEFINITIONS## Dental restraint can be broadly defined as anyform of restriction of movement by a patient in thedental environment.1,6,8,22 A dental restraint has thefollowing characteristics:

1. short duration (only the time it takes to com-plete a dental appointment);

2. limits movement of the head, body, and/orextremities;

3. prevents injury to the patient and/or dentalstaff during the procedure;

4. generates enough physical control to allowdental staff to complete needed dentalservices;

5. is usually well tolerated by the patient.22

A dental restraint may be physical, mechanical,chemical or a combination of these types ofrestraints.

Physical restraint is often called personalrestraint and refers to one person physically hold-ing another person's trunk, head and/or extremi-ties.4,6,23 Examples include head holds, handguarding, therapeutic holds, Hand-Over-Mouth-Exercise, and Hand-Over-Mouth with AirwayRestricted. Please refer to accompanying videofor a demonstration of these techniques and thenext section for descriptions.

Mechanical restraint refers to the use ofmechanical devices4,6,23 which assist the patient inremaining properly positioned during the


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course of dental treatment. Examples includePapoose Boards®, Pedi-Wraps®, sheets, straps,seat belts, towels, wrist bracelets, vests, andmouth props. There are many types of mouthprops such as the Molt® mouth prop,McKesson® bite block, tongue blades wrappedtogether with adhesive tape, metal finger guards,acrylic bite blocks and Open-Wide® mouthprops. Please refer to the accompanying videofor demonstration of these mechanical devices andthe next section for descriptions.

Chemical restraint (conscious sedation) isalso called pharmacological restraint and refers tothe use of a sedative or other drug to manage apatient's movements. In addition, conscious seda-tion usually requires mechanical and/or physicalrestraints to effectively manage a patient's move-ments. Drugs alone are not likely to restrain apatient.4 Please refer to Module 5 for more infor-mation.

## Positioning devices or immobilizers, are protec-tive supports for handicapped patients used duringthe period of dental treatment. These devices offerthe benefits of comfort to the patient and to the dentaloperator and increased stability for the patient.24

Examples include wheelchair head supports, beanbags, instant form immobilizers, pillows, towels, andwheelchair lifts. Please refer to the accompanyingvideo for demonstration of these devices and the nextsection for descriptions.## Combinations of physical, mechanical or chemi-cal restraints, or positioning devices may be used aslong as they are the least restrictive alternatives. Forexample, physical restraint may be required for theapplication of a mechanical device. Likewise, physi-cal restraint may be required to restrain a portion ofthe body that is not restrained by the mechanicaldevice.25 The accompanying video demonstratescombinations of physical restraint, mechanical re-straint, and stabilizers.

TYPES OF RESTRAINTSFollowing is a description of examples of physical

restraints, mechanical restraints, and stabilizers usedby dental staff in treating the disabled individual.The demonstration of each can be found in the ac-companying video. The purchasing information onthe commercially available products can be found inAppendix A.

# Physical RestraintsHead holds — Often side-to-side head move-

ments can be controlled by firmly cradling the pa-tient's head between the operator's upper arm andchest. This allows hands to be free to perform move-ments necessary in completing dental treatment.8,26

In addition, this position may give the patient a senseof security and permits the operator to "feel" thetenseness of the musculature so as to be able to antic-ipate quick movements that could cause injury to thepatient or operator.13

Some head movements cannot be controlled bythe operator cradling the patient's head. These move-ments may require another staff member to physi-cally hold the head.26 One method of controllinghead movements in highly resistive patients is to haveone staff member sit or kneel behind the patient'shead and firmly secure the head between the forearmand hands. The fingers are curled under the ear lobesto keep them out of the treatment field but the earsare not used to hold onto. When the patient relaxeshis/her head, the staff member relaxes the grip butremains in position to control sudden head jerks.Please refer to Appendix B for steps for implementa-tion of this technique.

Hand guarding — Hand guarding refers to thegentle prompting of a patient's hands back in placeon the armrests of the dental chair or the blocking ofhands if raised to the mouth.25 It is a type of physicalrestraint that is more of a passive touch than anactive hold.27 Hand guarding is often used by thedental assistant while the dentist is administeringlocal anesthesia or performing surgery.8,28

Therapeutic holds — Bodily movement of pa-tients can be controlled by a technique known as atherapeutic hold. It is a type of physical restraintwhich is protective and controlling in nature andassists in managing individuals who may be slingingarms or kicking.29 To place a therapeutic hold on apatient's arms, cross the patient's arms at the hip orwaist level and grasp the wrists firmly. Keep thepatient's hands tightly secured to the sides to preventscratching. To place a therapeutic hold on a patient'slegs, cross the legs at the ankles and grasp the anklesfirmly. When a therapeutic hold is placed on theankles, either physical or mechanical restraint mustalso be placed above the knees to prevent bucklingup of the knees by the patient. Therapeutic holds inthe dental environment are usually accomplished by


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a third person in addition to the dental operator andchairside dental assistant. Frequent checks should bemade of the patient's circulation to hands, fingers,and feet. The hold should be adjusted when the pa-tient relaxes or calms down.

Hand-Over-Mouth Exercise (HOME) —HOME is a physical restraint technique used onhysterical patients who are screaming, crying andtotally immune to verbal communication. The dentistplaces a hand firmly over the patient's mouth andcalmly explains to the patient that the hand will beremoved as soon as the appropriate behavior be-gins.21,30,31 The objectives of HOME are to gain thepatient's attention and to eliminate the patient's inap-propriate avoidance responses.21 It should only beused on patients who are able to understand andcommunicate and therefore has little use for the pa-tients being discussed in this module.17, 21,28,30-32

Hand-Over-Mouth with airway restricted(HOMAR) — HOMAR, or Hand-over-mouth withairway restricted, is a technique that was used in thepast on patients when additional applications ofHOME were unsuccessful. This type of physicalrestraint required the dentist to place a hand over thepatient's mouth with the thumb and forefinger lightlyclosing the nostrils. Fifteen seconds was the maxi-mum length of time the nostrils were closed. Whenthe patient started to cooperate, the dentist's handwas removed.30 The objectives were the same asthose for HOME. There is little support for use ofthis technique for any patient, and it has no place inthe care of patients discussed in this module.

## Mechanical RestraintsMouth props

Mouth props are often necessary for dental treat-ment of disabled patients because many lack theability to keep their mouths open or are unwilling todo so.10 Mouth props are mechanical restraints thatprotect the patient from injury that could occur dur-ing sudden and unexpected closing of the mouth.They also improve access and visibility for the dentalpractitioner,14 and protect the practitioner from in-jury.9,14,15 Many devices are available commerciallyand others can be easily fabricated.

Molt® mouth prop — Most practitioners preferthe adjustable Molt® mouth prop over others.14,33

This scissors-type mouth prop is commercially avail-able in adult, child and infant sizes. The metal

blades must be covered with a soft material, such assurgical rubber tubing, to prevent damage to the teethand soft tissues. The patient is able to remain openby biting against the rubber covered blades. TheMolt® mouth prop gives the dental practitioner themost positive control over mandibular movementsand can also be used to open the mouth wider ifnecessary.8 The dental practitioner and assistantmust stabilize the prop in the mouth by holding theprop close to or against the patient's face.12,15,34-36 Inaddition, the blades of the prop must be kept onposterior teeth to prevent subluxation of anteriorteeth, soft tissue lacerations,8,12, 15,26,36 or injury to theoperator's hand.36 Minor traumas may occur, suchas an imprint of the mouth prop on the cheek. Thismay be prevented by placing a gauze between theprop and the cheek. Trauma to the lip or corner ofthe mouth may occur if the patient moves duringinsertion. Any type of trauma caused by a mouthprop should be reported to the patient's caregiver. Adisadvantage of the Molt® mouth prop is its ex-pense.26. Molt® mouth props should not be used bynon-professionals such as technicians in the pa-tient's living unit.

McKesson® bite block — The McKesson® biteblock is another commercially available mouth prop.This wedge shaped rubber block can be placed be-tween the posterior teeth distal to the canines. Thedental practitioner or dental assistant should use afinger to hold the prop in place and to stop the pa-tient from pushing the bite block forward with thetongue.34 Dental floss should be attached to themouth prop to prevent the block from being swal-lowed and for easy removal.8,9,15,26,33 If bib clips areused, the floss can be attached to the clip to keep theprop from falling onto the floor.8 McKesson® biteblocks are available in five sizes: edentulous, largeadult, adult, child, and pedo. Most practitioners aremore successful in using this prop on children thanadults, since adults tend to open wider than the propopening and dislodge the prop.35 This prop is morelikely to be used for the cooperative patient who hasdifficulty keeping his/her mouth open or with patientsunder general anesthesia.

Tongue blades — Tongue blades wrapped to-gether with gauze and secured with adhesive tapeprovide a simple mouth prop.8,9,12,15,26,34,36 In additionto easy fabrication, this type of mouth prop is inex-pensive and can be customized for the amount of bite


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opening that is desired.9 The mouth can be openedwider by placing the tongue blades further posteri-orly.8 This type of mouth prop is used more on resi-dential living units or at home. Heavy prying orwedging forces may cause the tongue blades to splin-ter and may result in soft tissue lacerations.35 Theyshould be discarded after a single use.

Open-Wide® Mouth Prop — The Open-Wide®mouth prop is a relatively new commercially avail-able prop.9 It is available in two sizes, small andlarge. The prop itself consists of a soft durable foamhead attached to a tongue blade-like handle. It isinexpensive enough to be disposable, easy to use, andapplicable to professional as well as home use. TheOpen-Wide® mouth prop is very helpful with small,fragile patients.

Other Mouth Props — In addition to the previ-ously mentioned mouth props, an acrylic bite blockfashioned similar to a McKesson® bite block can becustom made for patients. Collapsible stainless steelfinger guards that were once available commercially,and metal tailor's thimbles can also be used as mouthprops.12,15,26,33,34,36 All are hard and can damageteeth, or slip and damage the clinician's fingers. Rub-ber door stops and rubber dog toys have been usedby some practitioners for mouth props but are re-garded by most as stigmatizing and offer little advan-tage over the McKesson® prop. Plastic evacuatortips are contraindicated for use as mouth props dueto possible splintering. Stainless steel evacuator tipsmay damage teeth and are not recommended.35

Papoose Board®The Papoose Board® is a commercially available

rigid board with soft canvas body wraps held byVelcro® that crisscross over the patient.8,11 It isavailable in three sizes: regular for children ages 2 to5 years, large for children ages 6-12 years, and extralarge for teenagers and adults.8,14 A removable headstabilizer may be attached to the rigid board.9,26,37

Many practitioners find the head stabilizer to bebulky and ineffective in controlling head movements.The Papoose Board® itself is very effective in re-straining torso and extremity movements.14,34 Manydental practitioners who treat disabled patients con-sider the Papoose Board® to be the only device capa-ble of controlling larger patients.8 The PapooseBoard® is somewhat costly (see Appendix A for costand purchasing information), but is a good invest-ment for the institutional dental clinic. The heavy

canvas straps may make a struggling patient hot,8,37

and make it difficult to monitor respirations.26 Inaddition, its rigid form does not conform to the cur-vature of some dental chairs 26,37 leaving an unsup-ported area between the board and the chair. Booksor pillows may be used to help support the board inthese instances.Pedi-Wrap®

Another commercially available full body re-straint is the Pedi-Wrap®. It consists of open weavenylon mesh that completely encircles the child patientand fastens with Velcro®.8,9,11,34 It is designed to fitchildren from infancy to about ten years and is avail-able in three sizes: small, medium, and large.8,9,11 Itslight material diminishes the possibility of overheat-ing.5,8,9,15,26,28,34 Many very young children might feelmore secure when wrapped in the Pedi-Wrap®.12,34,36

This may be because of an association between thePedi-Wrap® and a blanket.34 The nonrigid form ofthe Pedi-Wrap® allows children to be treated ineither an upright or reclining position. On the otherhand, its lack of rigidity is also its chief disadvan-tage. This can be overcome by adding a belt or strapto help keep the patient in the dental chair.8,26 Itscost is another disadvantage even though it is consid-erably less than the Papoose Board®.26

SheetsA bed sheet wrapped around a patient has been

shown to be an effective and inexpensive restraint fortorso and extremity movements.8,12,13,15,26,34,38 Onemethod is to have the patient stand with handspressed to the sides and wrap the patient in the sheetfrom the shoulders to the ankles.38 The sheet is thensecured with tape that is easy to cut. Anothermethod is to wrap the patient with the bed sheet in amummy-like fashion and fasten the ends with largesafety pins.8 This procedure is not usually frighten-ing and may even provide patients with a sense ofsecurity.Straps and Seat Belts

Automobile seat belts8,12,15,34 and straps ofcanvas,33,36 vinyl,8 Velcro®, or other materials maybe used to maintain patients in the proper chair posi-tion. Straps or seat belts may be placed around thewaist and under the patient's arms to secure the torsoto the back of the dental chair. A concern in thiscase is that they not interfere with the patient'sbreathing or the chair controls. Straps or seat beltsmay also be used to secure the patient's legs to the


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dental chair, in which case, the device should beplaced above the knees to prevent buckling up of theknees by the patient. The familiar automobile seatbelt and Velcro® strap tend to be easier to remove,less stigmatizing, and less frightening than other beltsor straps. Seat belts and straps may also be used inconjunction with mechanical restraints such as thePapoose Board® and Pedi-Wrap® for safety pur-poses. This will be demonstrated in the video.Towels

A simple restraint device is to wrap the patient'sarms in a towel, then wrap adhesive tape around thetowel and finally tape the arms to the chair armrests.8,26 The same procedure may be used to restrainthe patient's legs against the base of the dental chair.Care should be taken not to use adhesive tape thatmay remove the vinyl covering of some chairs. Afolded towel placed on a patient's forehead and heldby a dental assistant standing behind the dental chair,can limit minor head movements. This is a goodexample of a combination of a physical (dental assis-tant) and mechanical (towel) restraint. When thefolded towel cannot be held such as during radio-graphic procedures, the towel may be taped to thedental chair.Wrist Bracelets

Soft cloth straps may be wrapped around thepatient's arms and tied once, and then attached to thedental chair, wheelchair, or stretcher.15 Velcro®alone is usually ineffective in restraining strong armmovements. However, when combined with abuckle, even the strongest arm movements can usu-ally be limited (see Appendix C for more informa-tion). There are some commercially available ex-tremity holders, many of which add synthetic fur orfoam for the patient's comfort (see Appendix A forpurchasing information). Vests

Vests are commercially available which may beused to restrain a patient to a bed, wheelchair, oreven a dental chair. The vests may be purchased inseveral types of washable materials in sizes small,medium, and large (see Appendix A).

## Positioning Devices Many disabled individuals are wheelchair bound,

requiring extra personnel to move them to the dentalchair. The transfer, itself, can pose hazards to boththe staff and the patient.4 For some patients, the

wheelchair is a familiar physical environment, espe-cially the modified wheelchair. By providing dentaltreatment for them in their wheelchairs, their generalsense of security is increased and the threat of anxi-ety stemming from sudden changes is decreased.39

For these patients the positioning device providessupport and offers comfort during dental treatment.However, for the dentist treating the patient in thewheelchair, particularly those chairs with high andwide backs, lengthy procedures may place intolerablestrain on the dentist's back. It may be more practicalfor the dentist to transfer the patient to the dentalchair for lengthy procedures. When the patient ismoved from the wheelchair to the dental chair, posi-tioning devices once again may be helpful.

Wheelchair Head Supports — Wheelchair headsupports that can be installed quickly on the handlesof a wheelchair are available commercially.11,15 Themajor disadvantage of the manufactured device iscost (see Appendix A). Some practitioners haveadapted a headrest from a dental chair to a tubularattachment similar to the commercially availabledevice.40 Others have fabricated mounting bracketsthat are fixed to the wall and which will accommo-date adjustable slide-in headrests when needed.41 Aneven less expensive wheelchair head support can befabricated from plywood and padding. This Tshaped device can be inserted between the patient'sback and chair back and held in position by the pres-sure of the patient.42

Bean Bags — Several authors have described theuse of simple bean bag chairs for support and stabili-zation of the disabled patient.9,15 A bean bag chairmay be placed in the reclined dental chair and thepatient may then be placed on the bean bag. Thebeans will conform to the patient's body as the pa-tient settles into the position that is most comfort-able.9

Another option is to purchase a bag of replace-ment beans and fabricate several bean bags of vari-ous sizes. A long neck-roll and a standard bed pilloware useful sizes of bean bags that can be placed be-hind the head of the rigid patient. When fabricatingbean bags, an inner bag should contain the beans andbe covered by an outer bag of a vinyl-like materialthat can be easily cleaned.

Instant Form Immobilizers — Splinting appli-ances used in orthopedic medicine have been modi-fied for use during dental treatment as positioning


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devices. Several authors have described the use ofthese appliances.9,13,24,43 The device consists of arubberized vinyl bag partially filled with small plas-tic beads and a vacuum source to evacuate the air.The result is a customized molded form. The bagsare commercially available in ten different sizes andshapes. Bags may be placed on the patient's wheel-chair or stretcher, the dental chair, or the operatingroom table. A hand pump, high volume evacuator,surgical suction, or saliva ejector may be used as avacuum source.24 The bags can be reused by break-ing the vacuum which returns them to their softmoldable state. Their main disadvantage is cost (seeAppendix A).

Other Positioning Devices — Bed pillows orsandbags can be used as stabilizers for a patient'shead or torso and can fill in the space between thebody and the dental chair. For the patient who hasdifficulty in supporting his head, towels or sheepskinpads may be rolled up to provide support.11

There are commercially available wheelchair lifts(See Appendix A) that tilt the wheelchair to a reclin-ing position for the patient who must remain in thewheelchair for dental treatment.15 A less expensivealternative to purchasing a wheelchair lift is to fabri-cate wooden lifts that fit under the small front wheelsof the wheelchair. By placing the small wheels inthese wooden "boxes" the wheelchair can be tiltedapproximately 25 degrees to the posterior.44

CRITERIA FOR SELECTIONPatient management techniques for dental proce-

dures should be the least restrictive alternative, orthat technique which is the least intrusive availablefrom a hierarchical system of treatment options.This system includes psychologic management, phys-ical and mechanical restraints, followed by inhalationsedation, oral sedation, intramuscular sedation, intra-venous sedation, and finally progressing to generalanesthesia.32 Treatment preferences should usuallybe given to techniques that are the least restrictive.45

However, this should not be interpreted to mean thatone is required to proceed through the hierarchy oftreatment options in all cases.4,45,46 In an emergencysituation, the time factor does not permit progressionthrough the hierarchy.8,46

If restraints are indicated they should be placedon the patient before the patient becomes upset andunmanageable. The important point is that there is no

single technique for treating all patients, and specificproblems should be anticipated and handled on anindividual basis.3,11,28,32 Each patient must be evalu-ated each time to determine an acceptable level wheretreatment can be successfully and safely rendered.25

The practitioner must evaluate all relevant patientvariables to determine the technique that balancespresumed risks and presumed effectiveness.21,45 Therisks of general anesthesia usually outweigh thebenefits for the resistive patient who requires onlyprophylaxis, periodic exams, or minimal restora-tions.5,16 Other professionals such as psychologists,social workers, physicians, or nurses may need to beconsulted for additional information,4 but not fordecisions or approval. The choice of treatment op-tions is the responsibility of the dentist.## Behavior

Physically resistive behavior interferes with thesafe, effective delivery of dental services. The ma-jority of mentally retarded patients do not exhibitmaladaptive behavior in the dental environment.However, for the 30% of the mentally retarded popu-lation in general or for the estimated 60% of theinstitutionalized mentally retarded population whodo, the dental practitioner must be prepared.10,35 Thepatient who displays hyperactivity, aggression orsimilar behaviors in the waiting room will more thanlikely display these behaviors in the dental treatmentarea. The same holds true for the patient who dis-plays maladaptive behaviors in similar situationssuch as physical exams, blood drawing, or nail cut-ting. These behaviors are signals to the dental practi-tioner to consider behavior management techniquesfrom the hierarchical system of treatment options.For the extremely aggressive patient, the safest pro-cedure may be the immediate use of physical and/ormechanical restraints. For the mildly agitated pa-tient, psychological techniques should always beattempted first, followed by others, depending ontheir success or failure.3 For example, if behaviormodification corrects the maladaptive behavior, thereis no need for restraints or sedation.22

For patients where communication is severelyimpaired such as some autistic individuals, behaviormodification techniques should be attempted first.However, when oral disease is extensive or urgentthere is insufficient time for these techniques. Inthese cases restraints, sedation and general anesthesiaare reasonable options.4


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Behavior within the dental environment can varyfrom appointment to appointment, and within thesame appointment. However, past dental behavior isa good indicator for the need for restraints. If armand leg movements have been a problem in pastdental appointments, then the practitioner should beprepared to mechanically restrain the limbs.8 Treat-ment should first be attempted with no restraintsunless there is a history of unpredictable, violentbehavior which could be dangerous to the patientand/or staff. Otherwise, serious injury could resultbefore the decision to restrain is made. If movementsoccur, the least restrictive restraint, i.e. physicalholding of extremities should be the next course ofaction. If arm movements become continuous, me-chanical restraints such as wrist bracelets should beconsidered. If whole body movements begin, theoperator may need to place the patient in a full bodywrap such as a Papoose Board®. This examplefollows the progression from less restrictive to mostrestrictive behavior management techniques.

Where indicated, for physically resistive patients,r e s t r a i n t s s h o u l d b e u s e d w i t h o u treservation.2,21,26,47,48,49 It may even be considerednegligence in respect to both patient and operatorsafety for a dentist to provide dental treatment to avery resistive patient without the use of restraints.2

## Medical and Physical ConditionsThe medical and physical conditions of the patient

may contraindicate the use of some behavior man-agement techniques. 3,4,21,25,32 For example, generalanesthesia poses certain risks, particularly for thosepatients with severely compromised respiratory func-tions.3 These patients may have to be treated usingrestraints, or a combination of restraints and con-scious sedation. However, restraints and conscioussedation may also pose risks for these patients but insome cases may be a lower risk than general anesthe-sia. Deep sedation and general anesthesia may becontraindicated for patients with moderate or severescoliosis, due to the respiratory abnormalities associ-ated with these conditions.4

Many institutionalized patients have physicalabnormalities that must be considered in the decisionto use restraints. Individuals with spinal cord disor-ders, scoliosis, or cerebral palsy may require posi-tioning devices during dental treatment.4,26 Curva-tures of the spine may prohibit the use of full bodyrestraints such as a Papoose Board®. Extremities

may be rigid and fixed in positions that do not adaptwell to commercial restraining devices. Atlantoaxialinstability (a cervical spine abnormality), found in10-20% of individuals with Down Syndrome, man-dates caution in extending the neck.4 Many cerebralpalsy patients should not be placed in a completelysupine position (in order to minimize difficulties inswallowing).26 For these types of individuals therigid Papoose Board® could pose problems. Modifi-cations of mechanical restraints or the use of physi-cal restraints alone may be indicated. Small, fragilepatients must also be cautiously positioned to insureairway maintenance.

Physical disabilities may actually dictate the useof restraints. For the cerebral palsy patient withspasticity or athetosis (uncontrollable slow twisting,writhing movements), restraints can provide stabilityand assistance in cooperating with dental treat-ment.4,26

## Dental Treatment NeedsOne very important determinant in the decision to

use restraints is the amount of dental treatment re-quired by the patient.3,9,21,32,34 Resistant patients withrampant decay might best be treated under generalanesthesia on a one time visit as opposed to severallong appointments.3,26 Individuals with minimaldental needs requiring brief appointments might bestbe stabilized with restraints rather than general anes-thesia or sedation.3,5,16,38,48 As previously stated,emergency dental treatment needs often necessitaterestraints. In these situations time does not permitother techniques to be attempted.## Cognitive Functioning

The degree of management difficulty in the dentalenvironment is usually inversely proportional to thelevel of cognitive functioning.4 Also, individualswith severe/profound mental retardation will notgenerally profit from behavior modification tech-niques due to their severe cognitive and communica-tive deficits. Most practitioners agree restraints aremore frequently indicated for this group;3,4,21,26,34,38,50

however, an individualized approach is always pre-ferred. The practitioner should not assume thatbecause a patient is severely/profoundly retarded thatdental management problems are always to be ex-pected or that the need for restraints is inevitable.One very important reason restraints are needed inpatients with cognitive deficits is the impulsive na-ture of their movements.


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## Age Very young patients have difficulty understanding

and often need help in controlling their extremities.With these small patients, movements can manytimes be controlled through physical restraint by thecaretaker or dental assistant.26 Mechanical restraintsare not used as often for dental treatment in patientsunder the age of two. However, restraint is a validtreatment modality in many young patients.8,21,26,47,49

## Cost of Alternative MethodsAnother determinant in the selection process for

restraint usage is the economic expense of otheralternatives.3,9,50,51 When indicated, most institution-alized severely disabled patients are able to obtaindental treatment under general anesthesia. However,for many patients residing in the community, the useof general anesthesia for dental procedures is not arealistic option.50 Many health plans do not covergeneral anesthesia for dental treatment. If the familyis unable to bear the costs, the alternatives are to nottreat the patient or to use restraints and/or sedation.With the increasing costs associated with the use ofboth oral and parenteral sedation and general anes-thesia, restraints may be the safest and most costeffective method of providing dental treatment tosome patients.9

## SedationRestraints are indicated for sedated patients to

prevent harmful reflex movements and to providesafety.5,8,28,38,47,49,51 Wrist bracelets may be needed toprevent the sedated patient from placing his armsbehind his head. A full body restraint, such as aPapoose Board® or PEDI WRAP, may be useful inkeeping the patient from rolling over on his/her side.In any case, straps or seat belts should be used toprevent the patient from falling from the chair.## Protection

The need to protect the patient and dental stafffrom injury during dental treatment is a valid justifi-cation for restraint usage.2,5,8,17,21 As previouslystated, dental staff and patients themselves shouldnot be placed at risk by strict requirements for pro-gression through the hierarchy of treatment modali-ties. If a patient has consistently shown resistance todental procedures or a history of assault againstthose providing other treatment, then sharp instru-ments should not be utilized until potentially hazard-ous movements are controlled.2

The emergence of HIV infection and the longstanding risk of HBV infection has created new chal-lenges for patient and staff protection in the dentalsetting. The possibility of blood borne infections hasled to new infection control standards that requirethorough investigation of exposure incidents involv-ing sharp instruments. To avoid restraints and sub-ject staff to possible risks of infection in known resis-tive patients is inconsistent with accepted profes-sional standards.## External Forces

Many external forces play a role in behaviormanagement techniques dentists choose. Risingmalpractice insurance costs for those using sedationhave forced many practitioners to change their seda-tion usage.48,51,52 More stringent sedation guidelinesthat include training requirements, additional person-nel, and costly monitoring equipment (such as thepulse oximeter) have also led to a reduction in seda-tion usage.5,16,48,50-52

Recent legislation in several states regardingrestraints has led to limitations in restraintusage.47,48,52,53 However, recent surveys have shownthat the rate of use of restraint techniques (excludingthe use of HOME and HOMAR) has changed little.48

Another factor that has influenced the use ofrestraints in the dental environment is the public'sperception of restraint.2,16,48 Often dental restraintsare confused with general behavioral restraints. Im-ages of patients tied to beds or chairs for long peri-ods of time evoke negative connotations of restraintsfor the average person. The result may be limitationson restraint usage by human rights advocates andgovernmental agencies.2,16

Closely related to the public's perception of re-straints are parental attitudes. Papoose Boards®have been found to be unacceptable in some surveysof parental attitudes toward managementtechniques.50,54-56 Even though the use of PapooseBoards® may be objectionable to some, their use inan institutional setting is often mandatory. Theirusage should be fully explained to parents orguardians when requesting consent. The acceptabil-ity of management techniques by parents has beenshown to be dependent on the nature of the dentalprocedure. If the procedure is perceived by the par-ent to be more urgent and needed for the patient'swell-being and comfort, more restrictive techniquesbecome acceptable. Thus, there appears to be a


10

hierarchy of approval of management techniques byparents.54-56

In summary, as a result of external forces such asrising costs of malpractice insurance, stricter seda-tion guidelines, state legislation, public perceptionand parental acceptance, some dentists have beenforced to modify their restraint practices. In spite ofthese forces tending to limit the use of dentalrestraints, their use is still indicated and acceptablefor many patients with severe handicapping disor-ders.

LEGAL ISSUES## Applicable Laws

Constitutional Law — Several areas of law mayimpact the use of restraints in the dental treatment ofthe disabled patient. Constitutional laws are derivedfrom the Constitution of the United States and endowevery person in the US with certain inalienablerights.57 The Fifth Amendment to the Constitution isoften referred to as due process of law and providesthat no person shall be deprived of life, liberty, orproperty without due process of law.58 Disabledpatients cannot be deprived of liberties if resistive,regardless of whether they are involuntarily or volun-tarily committed to an institution, or treated in aprivate dental office. Protection for individuals withdiminished capabilities is guaranteed by the dueprocess clause.5,57

Due process of law attempts to strike a balancebetween individual interests and government inter-ests.58 Committed individuals have a constitutionalright to adequate health care.5,57 However, are per-sonal liberties violated when an individual is tempo-rarily restrained during dental treatment to protectthe dentist and the individual from injury? The bal-ancing test of individual interests vs. governmentinterests must be applied to answer this question.

From the individual's standpoint, if dental care iswithheld due to the individual's resistive behavior, theindividual's constitutionally guaranteed right to ade-quate medical care may have been violated.5 Failureto treat dental needs can lead to pain, loss of teeth,loss of self esteem, and death. If the individual isrestrained, then his personal freedoms are denied.

From the government's standpoint, early treatmentis in its best economic interest.5 To add to the di-lemma, for many institutions regulated by the federalgovernment, funds can be withdrawn if dental ser-

vices are not provided to all residents of the facility.2

Most would agree that curtailment of an individual'sliberty interests is minimal and temporary, and wouldrecommend the selective use of restraints in the den-tal care of the disabled.5 The benefit of good dentalcare outweighs the concern for individual rights insome instances.

Due process is not a fixed concept but varies withtime, place, and circumstance.58 The Constitutiononly demands that professional judgment be exer-cised when the question of liberty interests arises.5

Federal Law — All long term care facilities thatreceive federal funds are mandated by federal stat-utes to provide oral health care for their residents.2,57

Regulation and monitoring are carried out by federalagencies empowered to revoke funds if noncompli-ance exists.2 To meet the requirement of oral healthcare services for all residents, restraints are neces-sary in some instances. Federal statutes have al-lowed the temporary use of restraints in selectedcases for resistive patients; however, the decision touse restraints must be determined by a physician ordentist.5

The recent Americans with Disabilities Act, (Pub-lic Law 101-336), prohibits discrimination againstdisabled persons who seek services and employment.Disabled persons include those who are mentallyretarded or learning disabled, blind, hearingimpaired, wheelchair bound, or those who haveAIDS, mental illness or other diseases. The lawrequires auxiliary aids and services when necessaryto serve persons with disabilities unless the procure-ment of those aids would result in "undue burden".59

In the past, a practitioner may have refused to treatresistive patients if restraints were unavailable.Because the purchase of restraints, such as mouthprops and Papoose Boards®, would not pose an"undue burden", the practitioner may no longer beable to refuse treatment of resistive individuals on thebasis of unavailable aids.

If the disabled person is a "direct threat" or signif-icant risk to the health or safety of others that cannotbe eliminated by the use of auxiliary aids, practitio-ners may refuse treatment. Disruptive behavior suchas vocalizations and self-abusive actions are notconsidered to pose a direct threat to the health orsafety of others.59 Extremely resistive, uncontrolla-ble hitting, kicking, etc., could cause harm to others.Consideration should be given to treating these indi-


11

viduals in another setting under general anesthesia.If the practitioner does not have access to facilitiesthat provide these services, a referral should be madeto a facility that can accommodate the individual'sneeds.

Administrative Bodies — Individual states havethe power to enact laws through administrative bod-ies. These standards can be more restrictive thanfederal laws. Each state varies on the definition ofrestraint and selection criteria for restraintusage.4,5,7,11 In some states, protocols regardingrestraints vary among institutions within the state.5

One state has developed minimal guidelines for den-tal restraints in state facilities with the option foreach state facility to develop more stringent andcomprehensive policies and procedures.6 Otherstates are beginning to develop policies.60

A problem occurs when discrepancies arise be-tween the standards of administrative bodies, statestatutes, and federal laws.57 Recently, one state'sBoard of Dental Examiners suspended the license ofa mental health institution dentist for among othercharges "improper use of restraints."61 Officials atthe state level held that applicable state statutes werenot violated,60,61 but the State Board of Dental Ex-aminers ruled that it was against the standard of carefor a dentist "to force an elective dental procedure ona legally competent patient who refused treat-ment."60,61 The lesson to be learned by all practitio-ners is the importance of investigating the applicablelocal laws.4,5,7,11

Conflicts also may occur between the rules andregulations of different administrative bodies. Theboard of mental health, board of dentistry, and vari-ous advocacy groups may each have rules and regu-lations governing treatment for disabled individuals.Each administrative body may issue its own rulesand regulations with no regard for the rules andregulations of other administrative bodies. Theboard of dentistry may promulgate its own rules andregulations and investigate inquiries from otherboards and agencies. If the board of dentistry makesa decision against a dentist, the dentist may appealthe decision in an appropriate court of law. A courtof law is ultimately the final arbiter in determiningthe standard of care for treating handicapped pa-tients.57 The dentist who treats disabled patientswould be well advised to negotiate acceptable guide-lines for the use of restraints with various administra-

tive bodies before problems arise.2,57,60 Each admin-istrative body must be made aware of overlappingand conflicting rules and regulations.

Criminal Law — Charges of criminal assaultand battery for using restraints have been broughtagainst dentists.51,53,57 Authorities attempt to showunreasonable and/or unconsented to restraint by thedentist on the patient,57 or an unprivileged touchingof another person's body.30 The case could also bemade for willful nondisclosure if precise consent isnot obtained and could justify an award of punitivedamages designed to punish the dentist.18

Unfortunately, criminal assault is not covered bymost malpractice insurance policies.17,53 As will bediscussed in other sections, consent is mandatory forrestraints to be used. The use of restraints or anyprocedure without consent could result in a criminalcharge of assault and battery.17,18,30,54,62

Tort Law — A tort is an injury that results byvirtue of society's expectations regarding interper-sonal conduct.58 Standard of care and informedconsent are covered by tort law. Malpractice chargesmay be brought against the dentist who providestreatment below the standard of care, or who fails toobtain informed consent.17,57

If a state has established a standard of care re-garding restraints, as it has in one state,60,61 and apractitioner fails to adhere to this standard by per-forming improperly or negligently, malpracticecharges may be brought against the practitioner.Practitioners are legally bound to perform to thestandard of care in their state.## Informed Consent

Implied vs. Express Consent — Prior to theinitiation of any dental procedure, appropriate con-sent should be obtained.1,2,4,6,18-21 As previouslystated, failure to obtain informed consent could beboth a criminal offense (assault and battery) and apersonal tort (a malpractice charge).17,18

Consent may be either implied, or express. Ex-press consent is expressed in words, either written orspoken which unambiguously show intent.6,18,58

Implied consent arises from the signs, actions orconduct of an individual that raise the presumptionthat consent has been given.6,18,58 For example, whena legally competent adult seeks routine dental care,consent is implied. Consent is also implied when aparent takes a child to a dental office for routinedental care.20,30 Routine dental procedures (restora-


12

tion, cleaning, etc.) are those procedures the average,reasonable person would expect.20 However, theaverage, reasonable person may not expect proce-dures such as sedation, general anesthesia, nitrousoxide, or restraints.17,20 Therefore, these specialprocedures which many people are unfamiliar with,and which carry the potential for misuse, misinter-pretation, or adverse reactions, should have expressconsent.17-20,51 Written consent is preferred and maybe required at some institutions for any "unexpected"procedure. If properly documented, verbal or tele-phone consent may be adequate.

Elements of Consent — At least three elementsmust exist for consent to be legally valid: the firstelement is the mental capacity of the individual tomake reasonable decisions.6,63 Children less than 18years of age are considered incapable of makingdecisions in their best interest and consent must beobtained from their parent or legal guardian.4,62 Anindividual over 18 who has never been adjudicatedincompetent by a court, is legally competent in moststates.

Legally competent individuals may consent to orrefuse treatment.6 However, the individual mustfully comprehend the information that is presented.62

Clearly this is not possible if the patient is de factoincompetent. Frequently, disabled adult patientshave "compromised" abilities to make decisionsregarding their dental care, yet have never been adju-dicated incompetent.2,64 They may be competent toprovide consent in some situations but not in healthcare issues.4 For these individuals, some states allowa guardian to be appointed for medical decisions.Other states allow the dentist to petition the court forpermission to perform necessary treatment.2 Stillother states allow medical decisions to be made by anumber of people who have the individual's bestinterest in mind even though a legal guardian has notbeen appointed.4

It should never be assumed that the administrationof the institution has the legal authority to provideconsent for the individual who resides in an institu-tion.62 If an individual has been adjudicated incom-petent, the practitioner can obtain consent from thelegal guardian.6,62 However, many institutionalizedpatients who are "incompetent" have not been de-clared legally incompetent due to uninterested ornonexistent families, or inadequate staffing and sup-port to expedite guardianship proceedings. The

result is failure to provide appropriate dental carebecause treatment cannot be performed on these"incompetent" individuals who are not mentally ableto give valid legal consent.61,65 This scenario is notunique to institutional dentistry. The private practi-tioner who treats disabled rest or nursing home pa-tients, or developmentally disabled patients whoreside in group homes or with their parents, mustfollow the same requirements of valid legal consent.65

Needless to say, the determination of who givesconsent is a complicated issue that varies from stateto state. Legal advice should always be obtainedwhenever the practitioner is in doubt.4,5,63

The second element that must exist for consent tobe valid is that it must be informed.6,63 The individ-ual giving the consent must have enough informationto make an intelligent decision regarding whether toproceed with the procedure.6,18,20 Informed consentshould include an explanation of the nature, risks,and benefits of the procedure.4,6,17-21,62 In addition,information should be provided on the alternativeprocedures, and the risks of foregoing theprocedure.4,6,17-21 The person giving consent shouldhave adequate time to make a decision and ask ques-tions.17

The third element necessary for legally validconsent is that it must be given voluntarily.6,63 Theperson giving consent has the right to choose not toproceed with the procedure.6 The health care profes-sional may not coerce the person into consenting tothe procedure, even if the decision to forego the pro-cedure seems unreasonable to the health care profes-sional.18 If the practitioner detects any hesitation inthe person giving consent, it may be best not to per-form the procedure.20

Professional Community vs. Reasonable Pa-tient Standards — As previously stated one elementof legally valid consent is that the consent beinformed. The question arises as to what specificinformation a practitioner is required to provide. Twostandards of disclosure have evolved in the Americancourts – the professional community and the reason-able patient standards. In the past, most states ad-hered to the professional community standard. Thisstandard required a practitioner to make disclosuresthat the majority of local practitioners would deemreasonable under the same or similar circumstances.Professionals would be held liable for nondisclosure


13

only if the standard of professional practice wasviolated.18,19,30

With the increased focus on the informationalneeds of the average, reasonable patient rather thanon professional standards, a new reasonable patientor materiality standard has developed.18,30 This newstandard requires disclosure of all aspects of treat-ment that the average patient would consider signifi-cant.18,19,30 The reasonable patient standard reflectsthe societal demand of personal choice in health carematters for patients. It requires express consent forany procedure which may be considered objection-able to the average patient.

What constitutes appropriate practice as per-ceived by the patient becomes extremely important tothe practitioner.18 With the professional communitystandard, nondisclosure for some behavior manage-ment techniques would be reviewed as professionallyreasonable and consent would be implied as a part ofthe general consent to treatment.18,30 However, withthe reasonable patient standard, implied consentwould only apply to aspects of treatment that theaverage person would anticipate and approve, re-gardless of their acceptance in the professional com-munity.18,19,30

Since previous studies have shown restraints to beunacceptable by many parents,17,50,54-56 and the aver-age parent may not even be aware of these manage-ment techniques, the new reasonable patient stan-dard would require explicit disclosure of any infor-mation concerning restraints.18,19 If a dentist fails todisclose information a reasonable person would con-sider material to his decision to accept treatment,malpractice has been committed.30

Many practitioners lack knowledge as to whichinformed consent standard exists in their state.19 Thebest course of action for the prudent practitioner is topractice in a manner that will satisfy the most rigor-ous informed consent standard. In addition, expressconsent should be obtained for any procedure that theaverage person might find objectionable.18

Emergency Situations — In a true medical emer-gency, where any delay would endanger the life orhealth of the individual, treatment can be pursuedwithout consent in most states. However, in mostinstances dental needs would not be considered truemedical emergencies.62 If a disabled patient developsa severe abscess with threatened general health, thendental treatment can usually be initiated without

consent. Likewise, if the patient is resistive and itbecomes necessary to use a technique such as a phys-ical hold or mechanical restraint to avoid immediateinjury to the patient and/or staff during a dentalemergency, consent is usually implied.21 Only thoseprocedures that are necessary to preserve the life orhealth of the patient should be undertaken withoutconsent.

It is somewhat ironic that in an institutional set-ting where the dentist is obligated to provide dentalcare to the patients, patients may refuse treatment yetthe dentist is still responsible for the state of dentalhealth. However, an emergency condition reversesthe patient's decision to forego a procedure and al-lows the dentist to proceed with treatment without thepatient's consent.66

Other Consent Issues — Competent individualsmay consent for themselves and this consent may bewritten, verbal, or implied depending on the proce-dure. Individuals who are legally competent mayrefuse a procedure. If there is a question involvingthe capacity of a competent institutionalized or outpatient to consent to a procedure, it is advisable toseek consultation from the treatment team (or othersimilarly constituted organization). If a competentpatient initially consents to a special procedure suchas the use of a mouth prop or wrist bracelet, and thenexpresses a change of mind during the course oftreatment, the practitioner should use professionaljudgment to suspend the treatment at the earliestopportunity. In most instances, if a patient arrivesfor a dental procedure with restraints already ap-plied, no additional consent should be required.6

The length of time a consent remains valid de-pends on the type of procedure and the institution.Most consents require renewal at least annually andconsent for some special procedures expires at theend of 90 days. Consent in many psychiatric hospi-tals is valid for the length of hospitalization.

Guardians or competent patients have the right toexclude procedures when giving consent. For exam-ple, the guardian could elect to consent to allrestraints except for full body restraints. If consentis given for restraint during a dental examination, thesame consent could also cover restraints that mightbe needed for immediate dental treatment found atthe time of the examination.6

## Documentation


14

The importance of complete and accurate docu-mentation cannot be overstated. Both the consentprocess and restraint usage must be included in thedocumentation. For the institutionalized or grouphome patient, documentation may need to be placedin both the residential chart that accompanies thepatient and the patient's dental chart. Requirementswill vary from institution to institution. As previ-ously stated, explicit written consent is stronglyrecommended prior to the use of any type ofrestraint. Information regarding the indications,reasons, risks, benefits of restraints, types ofrestraints, alternatives to restraints and the conse-quences of not using restraints should be provided tothe legally responsible person or legally competentpatient. For most institutionalized patients this con-sent should be obtained upon admission,1 and up-dated annually or according to institutional policy.Consents should be witnessed, dated, and docu-mented. It is advisable to use a separate and clearlylabelled consent form for the use of restraints inaddition to a general consent form for routine treat-ment.20 Consent may be withdrawn or refused by theguardian of incompetent patients and minors, or bycompetent patients. Withdrawal or refusal of con-sent should be witnessed and documented.

Alternatives attempted prior to using restraintsand any related consultations should be documented.6

Some institutions require restraints to be authorizedwith a written order by a dentist or physician on a"Physician's Orders" sheet.6,45

The patient's treatment record, either the residen-tial record and/or the dental record, depending on theinstitution, might include the following:

1. date of use1,6

2. justification of use1,5,6,21

3. description of the restraint1,5,6,21

4. degree of effectiveness of the restraint1,6

5. duration of restraint1,5,6,21

Any periodic re-evaluation of the use of dental re-straints should be documented.

ETHICAL ISSUESThe practitioner who treats disabled patients is

often faced with a complex set of ethical issues.Many questions arise concerning the rights of theindividual with cognitive deficits and the individual'sability to participate in health care decisions.64,67 A

comprehensive discussion on the use of restraintsrequires consideration of these ethical issues.

One ethical concern is that the patient is in factincompetent and unable to participate in dental caredecisions. The assumption cannot be made that theinstitutionalized, elderly, medically diagnosed, orlegally incompetent patient is dentally incompetentand can not participate in treatment decisions.57,64

Often individuals cannot be placed in clear categoriesof competent and incompetent. They may be incapa-ble of making some decisions, but may be able toexpress an opinion against restraints and in favor ofsedation or general anesthesia. The ethical practitio-ner must look for the signs and indications that anindividual is capable of participating in the decisionprocess and must learn how to more fully empowerthese persons. Dentists should have a commitment toall patients, regardless of their level of disability, toassist them in participating in treatment decisions.64

A second ethical issue arises when the person istruly unable to participate in treatment decisions.How should other responsible decision makers pro-ceed in deciding for the person? Two sets of princi-ples emerge. One principle is to do what the individ-ual would have done if the individual were now capa-ble of making a decision. This concept is based onthe person's past actions and values.64 For the dis-abled patient who may have once been competent andis now incompetent, this principle may apply. How-ever, with most institutionalized developmentallydisabled patients another principle would apply. Theprinciple of "beneficence" directs responsible deci-sion makers to choose an action that would maximizethe patient's well-being.57,64

It is not a simple task to identify the course ofaction that maximizes the well-being of another.Clinicians often rely upon the standard of care tohelp them judge the best form of therapy in a givenclinical situation. For the compromised individual,treatment must meet the standard of care for theindividual's clinical circumstances.64 The technicalstandard of care for restorations and cavity prepara-tions in an institutional setting is the same as in thecommunity.2,66 Behavior management techniquessuch as restraints and sedation are not different butused more frequently in an institutional setting.2

Often a person's behavior makes it impossible toplace an acceptable restoration without the use ofbehavior management techniques such as restraints.


15

An unacceptable restoration placed without the aid ofrestraints does not maximize the well-being of thepatient.

A third ethical issue relates to the dentist's obliga-tion to assume the role of advocate.64,66 This advo-cacy is closely related to the ethical commitment ofthe dental professional to work for the individual'smaximal well-being.64 However, there is anothercomponent of advocacy that is the dentist's obligationto educate the guardian of an incompetent person.This advocacy may relate to a certain procedurewhich the dentist feels is in the patient's best inter-est.66 For example, a guardian may refuse restraintsand instead request general anesthesia for a disabledpatient requiring minimal dental work. It would bethe dentist's professional responsibility to educate theguardian on the risks vs. benefits of general anesthe-sia and restraints.

Finally, ethical consideration must be given to thelegally competent individual who has not been adju-dicated incompetent, but is clearly suffering fromcognitive deficits. If this individual refuses dentalprocedures, can treatment be imposed against the willof the individual? To impose treatment would de-prive the individual of the right to independentlymake decisions, or to be autonomous. The possibleuse of restraints and the associated denial of an indi-vidual's autonomy must be weighed against the ad-vantages of imposing treatment against the will of theindividual. The individual, institution, and dentalstaff would benefit from early treatment, yet forcedtreatment would be a denial of an individual's rights.Dentists may find it difficult NOT to intervene sincedentistry has trained its professionals to maintainhealth and comfort by early detection and treatmentof problems.67 However, the legally competent indi-vidual has a constitutionally guaranteed right torefuse treatment.

There are no precise answers to these ethicalissues. Individuals must be evaluated at each dentalvisit.64 Practitioners should always bear in mind acompetent individual's rights. In addition, the incom-petent individual's well-being should always be con-sidered.

ADMINISTRATIVE ISSUES## Policy Implications

Policies, protocols, and guidelines on restraintsmust be developed to provide safeguards for patients

and to reduce the staff's liability in respect to re-straints. It may be the responsibility of the adminis-tration of the institution to insure that reasonablestandards are in place, however, the dental staff mustoften assure that this occurs. Consultation with anattorney, appropriate state officials, or the statedental board may be necessary before establishingsome office policies.5

There are several elements that should be includedin the development of policies, protocols, and guide-lines on the use of restraints. One of the first consid-erations should be to formulate a written philosophythat commits to using the least restrictive means ofreaching a particular clinical goal.45,63 Other ele-ments that should be included are the criteria forselection,2,45 consent requirements, 2,45,63

monitoring45,63 and documentation. The written docu-ment should define the different types of restraintsand give examples.2,45 The document author shouldinclude an explanation of each type of restraint, anda clinical photograph or illustration if possible.Information on staff training 45,63 and infection con-trol should also be included in the document. Gener-ally, more complete and inclusive policies will pro-vide better protection for patients and staff.45

The document should cite written rules and regu-lations promulgated by different administrative bod-ies and agencies.57,63 It is advisable to have the docu-ment reviewed by a committee of knowledgeableprofessionals such as a peer review committee and/orthe Human Rights Committee.45,63 All communitiesof interest, (e.g. the institution's director, medicaldirector, advocates, and state dental board), shouldreceive copies.2,57 By sharing the policy with inter-ested parties, any questions or concerns can be ad-dressed upon receipt of the document.57

These policies, protocols, and guidelines shouldnot bias clinicians toward the least regulated proce-dures or interventions. The practitioner is profes-sionally obligated to use the most effective proce-dures, rather than merely choosing those that are lessregulated.63 (For example, some practitioners maychoose to forgo restraints, except for emergencytreatment, if policies require extensive report writingand committee meetings.)

Restraint usage should be monitored for compli-ance with restraint policies. Policies should establishdocumentation protocols that allow ready retrieval ofinformation related to restraint usage.


16

## Staff TrainingAdequate training regarding the clinical use of

restraints is essential for the protection of both theindividual requiring restraints and the staff imple-menting the restraint. Staff must be protected fromboth legal and physical harm. The institution will notbe able to legally defend the use of these interven-tions unless reasonable efforts have been made totrain staff.63

All staff involved in implementing restrictivep r o c e d u r e s s h o u l d h a v e a d e q u a t etraining.1,6,23,45,46,63,68 Training should be documentedand the procedure reviewed with staff on a regularbasis.6,45 Training should include information on thetypes of restraints and their correct application, thecriteria for selection, applicable laws, informed con-sent, documentation procedures, infection controlprocedures, possible risks of restraints, and monitor-ing requirements. Training could be provided by aknowledgeable individual or a team of experts fromvarious departments at the institution (e.g. advocacy,records, staff development, psychology, etc.) Train-ing could consist of written materials and videos ordemonstrations. This module is a good starting pointbut should be supplemented with information appli-cable to individual agencies, institutions, and states.## Infection Control Recommendations

Proper infection control techniques protect bothstaff and patients from acquiring infectious diseasesassociated with dental care. Any instrument thatcomes in contact with body fluids (saliva, blood, orurine) must be cleaned and disinfected. Devices thatcan be sterilized should be sterilized by a method thatdoes not damage the materials.

Both the Molt® mouth prop and the McKesson®bite block can be sterilized by steam autoclave, ethyl-ene oxide, or chemical agents. Because sterilizationby chemical agents cannot be monitored biologically,it is not the preferred method of sterilization. Steril-ization by steam autoclave or ethylene oxide is pre-ferred. The rubber tubing can be removed from theMolt® mouth prop prior to sterilization, placed in anautoclavable bag along with the Molt® prop andsterilized in the steam autoclave. Or the tubing maybe left on the prop during steam autoclaving. (Pleaserefer to appendix D for more information.) Oneshould wet the tubing with water or a lubricant suchas petroleum jelly or with ultrasonic cleaning solu-tion to replace the rubber on the metal tips. The

tubing should be discarded when it becomes frayed,sticky or unsightly. One should remove the string ordental floss attached to the McKesson® bite blockafter each use. New string or floss may be attachedprior to sterilization or at the time of use. TheMolt® mouth prop and the McKesson® bite blockshould be kept wrapped or packaged until used.

Tongue blades are disposable and should be dis-carded after each usage. The Open-Wide® mouthprop can be rinsed with warm water and sent homeor to the residential unit with a trained caregiver;however, it is intended to be disposable and shouldNOT be reused on different patients. Other mouthprops, such as custom made acrylic bite blocks,collapsible stainless steel finger guards, and tailor'sthimbles, should be sterilized by ethylene oxide orsteam autoclave.

The vinyl covered board component of a PapooseBoard® may be sprayed with an ADA-approveddisinfectant after each use. If the fabric componentis contaminated with body fluids, it should be re-moved from the board and washed with detergent.The fabric portion should be air dried, if time per-mits. Drying may be accomplished in an automaticdryer, but this method may damage the Velcro® ifother fabrics such as terry cloth are dried in the sameload. The mesh Pedi-Wrap® should also be washedwith detergent and air dried if it becomes contami-nated with body fluids.

Sheets, towels, and some wrist bracelets andstraps may be laundered in an automatic washer anddryer, unless they have a Velcro® component inwhich case hand washing and air drying should beemployed to prolong the life of the Velcro®. Seatbelts or vests with metal buckles should also be handwashed and air dried.

Plastic garbage bags may be used as protectivecoverings for head supports, bean bags, instant formimmobilizers, and pillows. If a device cannot becovered with a protective covering, it should becleaned and disinfected between patients, or whenvisibly contaminated with body fluids.

SIDE EFFECTS## Psychological Effect on Patients

Most practitioners agree that psychologicaltrauma is unlikely when restraints are properly usedon children of normal mentalities.8,18,47,49 If restraintscan be used without emotional damage on children of


17

normal mentalities, then the absence of emotionaldamage is likely in developmentally disabled individ-uals.8 Restraints may even provide a sense of secu-rity to very young children,34,36 physically disabledindividuals,8 , 3 6 developmentally disabledindividuals,8,36 and sedated individuals.12

For some developmentally disabled individuals,restraints are a positive reinforcer.45,69 These individ-uals actually appear to enjoy restraint in mechanicaldevices and will resist their removal. For these indi-viduals, restraint may be associated with physicalcontact when an individual has been deprived ofphysical contact.69

Mechanical restraints have been suggested to beless stressful to the patient than physical holding bymultiple auxiliaries.9,12,36 Physical holds may unin-tentionally signify empowerment,12,36 clutter the treat-ment environment,9,12 or allow non-verbal transfer ofanxieties from the staff to the patient.9 Data on thelong term psychological effects of restraints areunavailable.49,50 Controlled longitudinal research inthis area would be of benefit to both the practitionerand the disabled patients.## Physical Harm to Patients

The use of restraints must be continuously moni-tored by trained staff to prevent restraint-relatedinjuries to patients.1,6,26 The majority of restraint-related injuries consist of minor bruises andscratches, although serious injuries such as fractures,broken teeth, and respiratory distress have beenreported.68

Studies have shown that mildly and moderatelymentally retarded individuals in an institution are ata greater risk of injury from restraints than severelyor profoundly mentally retarded individuals.23,68 Onestudy has shown higher patient injury rates with theuse of physical restraint than mechanical restraint;however, the study does not recommend the uniformuse of mechanical rather than physical restraint.Risks are also associated with mechanical restraint.Consideration must be given to the fact that somemechanical restraints cannot be terminated quickly inthe event of a seizure or medical complication. Thesame study reported higher patient injury rates withemergency restraint procedures than with plannedprocedures.68

Precautions must be followed with the use of anyrestraint either mechanical or physical, emergency orplanned. In addition, a restrained individual should

never be left unattended.1,6 Many safety consider-ations have already been addressed in the discussionon the various types of restraints. For example, theMolt® mouth prop must be carefully monitored toavoid subluxation of teeth and soft tissue lacerations.Mouth props should not force the mouth open be-yond its natural limits,26 should not be opened be-yond the amount required for treatment, and shouldbe removed periodically to prevent fatigue.32 Thepatient's mouth should be open prior to the insertionof any mouth prop to avoid injury to the temporo-mandibular joint.9

Overheating may result during long periods ofrestraint with a full body wrap such as a PapooseBoard® or bed sheet. Full body restraints requireconstant supervision to prevent the individual fromrolling out of the chair. The rigid design of the smallPapoose Board® may not allow extension of thehead and neck for airway patency in sedated children.Folded towels may be placed under the neck andshoulders of the individual, or the Papoose Board®itself may be modified with a hinge.37

Any type of strap, belt or tie device must be ad-justed so that neither the circulation nor respiration iscompromised.32 Temporary nerve injuries due topressure from restraint buckles,70 and wrist cuffs 71

have been reported. Individuals with spinal cordinjuries may not perceive pressure or injury to nervesand must also be carefully monitored.4

Any abrasion, bruising or redness that can beattributed to a restraint device or physical holdshould be pointed out to caregivers. Obvious inju-ries, whether minor or serious, should be documentedin the patient's record. In addition, the institutionmay require an "Incident Report" to be completed.## Physical Injury to Staff

Injuries to staff have occurred during restraintprocedures.23,68 The overall rate of staff injury at-tributable to restraint is low considering the amountof physical struggle that often accompanies the im-plementation of a restraint. Staff injuries result indiscomfort and pain for the staff, economic costs tothe facility (medical expenses, worker compensation,replacement costs, and legal costs), lower staff mo-rale, and increased staff turnover.23

Data from a recent study of staff injuries showedhigher numbers of male staff injured than femalestaff.23 Experience suggests that male staff are morefrequently needed to implement restraints with diffi-


18

cult individuals, thereby increasing their chances ofinjury. Most injuries in this study were minorscratches or abrasions. Additional data from thisstudy suggest that the use of mechanical restraint issafer for staff than the use of physical restraint foraggressive and disruptive individuals. Mechanicalrestraints may be safer due to the more limitedamount of direct physical contact involved with suchrestraints. In this study, emergency physical restraintincurred the highest number of staff injuries.Planned mechanical restraint incurred the lowestnumber of staff injuries.23

Staff training in restraint procedures appears toreduce the rate of staff injury. Annual training isrecommended. Proactive efforts to anticipate re-straint strategy for emergency treatment of individu-als who only rarely require restraint may also mini-mize the injury rates of staff.23

CONCLUSIONFor some disabled individuals, restraints are a

necessary technique for managing potentially danger-ous and maladaptive behaviors in the dental environ-ment. The decision to employ restraints and theselection of appropriate restraint is a complex taskwhich requires the consideration of multiple factors.Consideration must be given to legal issues such asapplicable laws and informed consent. Often ethicalquestions are difficult, if not impossible to answer.Comprehensive policies covering all aspects of re-straint usage are essential to protect both the patientwho is restrained and the staff who implement therestraint. Whenever restraints are used the ultimategoal should be to implement the least restrictivealternative for the individual.

## REFERENCES1. Southern Association of Institutional Dentists.

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3. Fox LA. The handicapped child. Dental Clinics ofNorth America 1974; 18(3) : 535-44.

4. American Dental Association Council on Commu-nity Health, Hospital, Institutional, and MedicalAffairs. Patients With Physical and Mental Dis-

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ad hoc committee report: the use of restraints inthe delivery of dental care for the handicapped -legal, ethical, and medical considerations. SpecialCare in Dentistry 1987 ; 7 (6) : 253-6.

6. North Carolina Division of Mental Health, Devel-opmental Disabilities, and Substance Abuse Ser-vices. Minimal Guidelines for Dental Proceduresin State Facilities. APSP 10-2. 1991 : 1-10.

7. Academy of Dentistry for the Handicapped Recom-mendations for the use of restraints in the deliveryof dental care for the handicapped.

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15. Novak AJ. Dentistry for the Handicapped Patient.St. Louis: Mosby; 1976: 202-6, 287-90.

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18. Hagan PP, Hagan JP, Fields HW, Machen JB. Thelegal status of informed consent for behavior man-agement techniques in pediatric dentistry. PediatricDentistry 1984;6(4):204-8.

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20. Klein A. Physical restraint, informed consent, andthe child patient. Journal of Dentistry for Children1988;55(2):121-2.

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22. Davila JM. Restraint and sedation of a dental pa-tient with developmental disabilities. Special Carein Dentistry 1990; 10(6):210-12.

23. Hill J, Spreat S. Staff injury rates associated withimplementation of contingent restraint. MentalRetardation 1987;25(3):141-5.

24. Corcoran JW, Bender PA. Stabilization of the re-tarded child for dental procedures. Mental Retarda-tion 1971;9(6):26-8.

25. Restraint devices-social, orthopedic, medical, den-tal. O'Berry Center Administrative Policy Manual.Goldsboro, NC. 1987.

26. Lynch TR, Jones JE, Weddell JA. Dental problemsof the handicapped child. Dentistry for the Childand Adolescent. St. Louis: Mosby; 1983:642-86.

27. Restraint devices-techniques for use during dentaltreatment. Broughton Hospital Dental Policy Man-ual. Morganton, NC.1989:1-2.

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29. North Carolina Division of Mental Health, Devel-opmental Disabilities and Substance Abuse Ser-vices. Protective Intervention Course Manual.APSM 80-2.1982.

30. Bowers LT. The legality of using HOME for man-agement of child behaviors. Journal of Dentistry forChildren 1982; 49 (4):257-65.

31. Rombom HM. Behavioral techniques in pedo-dontics: the hand-over-mouth technique. Journal ofDentistry for Children 1981;48 (3):208-10.

32. Dragon A, Goldstein T. Office management of theambulatory patient. Dental Clinics of North Amer-ica 1974;18(3):671-81.

33. Bernick SM. Adjuncts for the dental managementof handicapped patients. Proceedings of the FirstInternational Congress on Dentistry for the Handi-capped, Atlantic City, NJ, Academy of Dentistry forthe Handicapped, 1971;29-33.

34. Pinkham JR. The handicapped patient. Textbook ofPediatric Dentistry. Baltimore: Williams andWilkins;1980:481-95.

35. Dicks JL. Personal communication. Brookrun Den-tal Director. Dunwoody, Georgia. July 1992.

36. Beaver HA. Control mechanisms for the specialcare pediatric patient. Journal of the MichiganDental Association 1970;52: 34-6.

37. Adair SM, Durr DP. Modification of PapooseBoard® restraint to facilitate airway managementof the sedated pediatric dental patient. PediatricDentistry 1987;9(2):163-5.

38. Menius JA. Patient management of the handi-capped child. Dental Management of the Handi-capped Child. Birmingham, Alabama: Center forDevelopmental and Learning Disorders; 1970:39-42.

39. Zyon GM, et al. Adapted dental chair for thewheelchair patient. Pennsylvania Dental Journal1968;35(8):278-80.

40. McGowan RH. Headrest for patients in wheel-chairs. British Dental Journal 1974;136(5):203-4.

41. Kilfoil JO, Popovitch PP. Auxiliary headrestmounting bracket for handicapped patients. Journalof Prosthetic Dentistry 1977;38(3):347-9.

42. Grewcock RJ. Head support for wheelchair. BritishDental Journal 1986;160(10):344.

43. Bender PA. The instant body form immobilizer.Dental Management of the Handicapped Child.Birmingham, Alabama: Center for Developmentaland Learning Disorders; 1970:38.

44. Napierski GE. Positioning wheelchair patients fordental treatment. Journal of Prosthetic Dentistry1982;47(2): 217-8.

45. Spreat S, Lipinski OP. A survey of state policiesregarding the use of restrictive/aversive behaviormodification procedures. Behavioral ResidentialTreatment 1986;1(2): 137-

46. Morgan RL, Striefel S, Baer R, Percival G. Regula-tory behavioral procedures for individuals withhandicaps: a review of state department standards.Research in Developmental Disabilities1991;12(1):63-85.

47. Acs G, Burke MJ, Musson CM. An updated surveyon the utilization of hand over mouth (HOM) andrestraint in postdoctoral pediatric dental education.Pediatric Dentistry 1990;12(5):298-302.

48. Acs G, Musson CAW, Burke MJ. Current teachingof restraint and sedation in pediatric dentistry; asurvey of program directors. Pediatric Dentistry1990;12(6):364-7.

49. Davis MJ, Rombom HM. Survey of the utilizationand rationale for hand-over-mouth (HOM) andrestraint in postdoctoral pedodontic education.Pediatric Dentistry 1979;1(2);87-90.

50. Harrison RL, Feigal RJ. Challenges and dilemmasin behavior guidance of the pediatric dental patient.Journal of Canadian Dental Association1989;55(10):793-5.

51. Nathan JE. Management of the difficult child: asurvey of pediatric dentists' use of restraints, seda-


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tion and general anesthesia. Journal of Dentistryfor Children 1989;56 (4):293-301.

52. Davis MJ. Conscious sedation practices in pediatricdentistry : a survey of members of the AmericanBoard of Pediatric Dentistry College of Diplomates.Pediatric Dentistry 1988;10(4):328-9.

53. Schuman NJ, Williams NJ, McIlveen LP, SharpHK. Dentists charged with criminal assault andchild abuse - an occupational hazard. Journal ofPublic Health Dentistry 1987;47:36.

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55. Fields HW, Murphy MG, Machen JB. Acceptabil-ity of various behavior management techniquesrelative to types of dental treatment. Pediatric Den-tistry 1984;6(4):199-203.

56. Murphy MG, Machen JB, Fields HW. Parentalacceptance of pediatric dentistry behavior manage-ment techniques. Pediatr ic Dentis t ry1984;6(4):193-8.

57. Klein A. Legal issues in dentistry for the handi-capped. Special Care in Dentistry 1990;10 (6):204-5.

58. Gifis SH. Law Dictionary. New York: Barron;1984:30,145-6,172,186,220,482.

59. American Dental Association Division of LegalAffairs. Americans with disabilities act: questionsand answers.1992:1-12.

60. Spaeth D. State boards may advise on restraints.ADA News 1992;23 (9):16.

61. Spaeth D. Court upholds suspension/decision af-fects handicapped care. ADA News 1991;22(21):24-9.

62. Rozovsky LE. Dentistry - the law and mental retar-dation. Oral Health 1988:78 (4):45-7.

63. Griffin RG. An administrative perspective onguidelines for behavior modification: the creationof a legally safe environment. Behavior Therapist1980;3 (1):5-7.

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65. Brown A. Institutional and private consent. NorthCarolina Dental Gazette 1992; 14 (3):2.

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68. Spreat S, Lipinski D, Hill J, Halpin ME. Safetyindices associated with the use of contingent re-straint procedures.Applied Research Mental Retardation 1986; 7(4):475-81.69.

69. Singh NN, Winton ASW, Ball PM. Effects ofphysical restraint on the behavior of hyperactivementally retarded persons. American Journal ofMental Deficiency 1984; 89(1):16-22.

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71. Levin RA, Felsenthal G. Handcuff neuropathy :two unusual cases. Archives of Physical Medicineand Rehabilitation ion 1984;65 : 41-3.

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Appendix A(Prices Effective 10-21-92)

Product Manufacturer Cost

Molt® Mouth Prop Hu-Friedy $165.003232 N. Rockwell St. (all sizes)Chicago, Il. 60618

McKesson® Mouth Prop M.D.T. $11.007371 Spartan Blvd. E. (all sizes)N. Charleston, SC 29418

or Crescent Dental Mfg. Co. Pedo $11.007750 W. 47th St. Child $10.00Lyons, Il 60534 Adult $10.001-800-323-8952 Lg. Adult $12.50

Edentulous $13.00

Open-Wide® Mouth Prop Specialized Care Co. 100 Small $43.5015 Renee Court 100 Lg. $43.50Edison, NJ 0882-3634 50 Lg/50sm $43.501-800-722-7375

Papoose Board® Olympia Medical Reg. $149.504400 Seventh South Lg. $292.50Seattle, WA 98108 X-lg $309.50

1-800-426-0353

Pedi-Wrap® Specialized Care Co. Small $75.0015 Renee Court Medium $77.00Edison, NJ 08820-3634 Large $79.001-800-722-7375

Wheelchair Headrest Metal Dynamics Corp. $545.009324 State RoadPhiladelphia, PA 19114215-632-8889

Wheelchair Automatic Lift Metal Dynamics Corp. $5250.009324 State RoadPhiladelphia, PA 19114215-632-8889

Vac-Pac® Olympic Medical Elect. pump $156.504400 Seventh South Hand pump $72.95Seattle, WA 98108 10 different sizes priced1-800-426-0353 from $129 - $444

Restraining belts, J.T.Poseywrists cuffs, vests, etc. 5635 Peck Rd Call for prices

Arcadia, CA 91006-00201-800-423-4292


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Kneel, sit or squat behind the patient’shead.

Secure the patient’s head between theforearms.

Appendix B Dental Head Hold

The Dental Head Hold is a method of controlling head movementin highly resistive dental patients. In the absence of such aprocedure, patients could be at risk and the dental operator is unableto work without resistiveness from the patient. The method does notinterfere with delivery of dental treatment. The staff member who isexecuting the hold is behind the resident, out of the treatment field,lessening the possibility of needle sticks , injury by instruments, etc.

Basically, the Dental Head Hold is a physical restraint methodused in conjunction with a papoose board. One dental staff member kneels or sits behind the patient'shead and firmly secures the head between the forearm and hands. The fingers are curled under the earlobes to keep them out of the treatment field, but the ears are not used to hold onto. When the patientrelaxes his/her head, the staff member relaxes the grip but remains in position to control sudden headjerks. Once the first staff member is in position the dental operator is able to work safely.

The hold should be documented on the Dental Restraint Record. The reason for the restraint shouldbe recorded as "excessive head movement."

Steps for Implementation- Remove watches and other jewelry and don gloves- Remove earrings from the patient


23

Curl the fingers under the patients ear lobes butDO NOT hold onto the ears. The forearmsshould “hold” the head in position.

The dental operator can begin treatment.


24

Appendix C

Appendix D

Documents

M ANAGING M ALADAPTIVE B EHAVIORS The Use of Dental ... · SOUTHERN A SSOCIATION OF INSTITUTIONAL D ENTISTS — Self-Study Course Module 6 1 M ANAGING M ALADAPTIVE B EHAVIORS The