21 minute read
How Do We Protect a Child's Psychological Health During Procedures That Use Protective Stabilization?
Dennis Paul Nutter, DDS
ABSTRACT
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Background: If a child experiences pain during procedures while protective stabilization is in place, they will experience suffering, central sensitization and classical fear conditioning in direct proportion to the duration and intensity of their procedure pain. Rigorous and reliable procedure pain assessment during procedures is imperative if children’s psychological health is to be protected when protective stabilization is deployed.
Types of studies reviewed: A review of pain assessment guidelines and best practice recommendations, their supporting literature and the pain assessment practices of pediatric dentists was undertaken to determine if current pediatric dental pain assessment methodology conforms to best practice recommendations.
Results: Best practice recommendations for pain assessment in pediatrics allow the child to determine their own procedure pain intensity level, either by self-report or, for children younger than age 7, by observation of their distress behavior. Current practice in pediatric dentistry is to target behavior for assessment during invasive procedures and allow the dentist to decide the level of a child’s procedure pain that is associated with that behavior. Dentists, physicians and nurses all tend to underestimate their patients’ pain if they are allowed to make that determination.
Practical implications: Many pediatric dentists practice a method of procedure pain assessment that does not conform to best practice recommendations. Three practice recommendations are proposed to improve pain outcomes and protect the psychological health of children during potentially painful procedures, especially those involving the use of protective stabilization.
Keywords: Protective stabilization, papoose board, restraint, sensitization, fear, conditioning, pain, behavior management, pain justification, medical ethics
Editor’s Note: This issue of the Journal features two separate but companion manuscripts on pediatric dental care and the use of protective stabilization. The topic is controversial and instead of publishing one article and waiting for responses, we are publishing a second article to allow readers to immediately appreciate the range of opinions on the topic. Dennis Nutter, DDS, authored this article and Paul S. Casamassimo, DDS, MS; Beau Meyer, DDS, MPH; and Janice A Townsend, DDS, MS, wrote the second piece. They offer a thoughtful response in their article beginning on page 465. Both perspectives are informed by the experience and expertise of their pediatric dentist authors.
AUTHOR
Dennis Paul Nutter, DDS, is a diplomate of the American Board of Pediatric Dentistry and is immediate past president of the Western Society of Pediatric Dentistry. He has authored articles and lectured nationally and internationally on pediatric procedure pain assessment. He is a diplomate of the American Board of Pediatric Dentistry, a fellow of the American College of Dentists and a fellow of the Pierre Fauchard Academy. He is in private practice in Fairfield, California. Conflict of Interest Disclosure: None reported.
The American Academy of Pediatric Dentistry (AAPD) defines “protective stabilization” as the “physical limitation of a patient’s movement by a person or restrictive equipment or materials … to safely provide examination, diagnosis and/or treatment.” 1 While protective stabilization refers to a constellation of immobilization equipment and methods, it most commonly refers to papoose-style restraining devices. During treatment, it is deployed predominately in children under age 5. In 2004, 36% of pediatric dentists who were members of the AAPD preferred to restrain a 3- or 4-year-old patient for limited treatment needs rather than use sedation. In 2006, a systematic review of pediatric dental sedation studies found that almost half of the clinicians used papoose board immobilization when sedating children for procedures. 3 The average age of the child subjects was 4.5 years even though the inclusion criteria accepted subjects up to age 16. In some European countries, using a papoose board to restrain children during invasive procedures is legally restricted. 4 Its use in the U.S. is not without controversy.
The AAPD’s best practice recommendation for protective stabilization states that its goal is to “prevent or minimize psychological distress and decrease the risk of physical injury to the patient, parent and staff.” 1 The policy’s authors warn that protective stabilization carries a risk of “psychological effects” and that the “psychological health of the patient should override other factors.” The recommendation is also to terminate protective stabilization if a child is experiencing “severe emotional distress.” Protective stabilization was conceptualized with the intent that its use not result in harm to the “psychological health of the child.”
Clinicians have an ethical duty to “do no harm.” The concept of harm as it is applied to medical procedures is more broadly defined than is the concept of “hurt.” In the context of a medical procedure, a child is harmed when the patient experiences more negative procedural sequelae than necessary in order to obtain the intended benefit. 10–12 Pain is a prime, negative procedural sequelae to be considered, but it is not the only one. “Harm” is not equivalent to “hurt.”
Procedures commonly cross a child’s pain threshold without harming them. A good injection technique can result in low levels of pain that are below the child’s pain tolerance level and are justified given the risk of alternatives. However, if a child experiences pain beyond their pain tolerance level by one procedure and if by an alternate procedure the child would not have experienced high intensity pain yet obtained the same benefit, then the child has been harmed.
Young children have only an emerging capacity to exercise autonomous decisions regarding their health. Their inability to effectively self-advocate warrants practice recommendations that protect their right to have their pain effectively managed.
This paper proposes three practice recommendations to mitigate the ability of evaluator bias to enter the methodology of pediatric procedure pain assessment. Two examples will illustrate how the proposed recommendations can affect clinical decisions to employ or not employ immobilizing restraint during procedures involving tissue trauma. The definitions of relevant terms are provided in the APPENDIX.
Practice Recommendation One
Until an accurate, reliable, clinically useful, objective measure of pediatric procedure pain is found, distress behavior that occurs coincident with procedural tissue trauma is pain behavior until the child says otherwise.
Rationale: Deeply imbedded in the clinical culture of pediatric dentistry is the suspicion that some children exhibit pain behaviors during procedures that are not authentic. 2,15–20 Young children have difficulty with their self-report of pain. 21,22 Children are known to exhibit pain behavior when there is no procedure pain stimulus. This pain magnification — an exaggerated response that is an attempt by the child to convince an observer that they really are experiencing some level of pain or expect to experience it 23 — is the behavioral manifestation of anxiety or fear.
Behavior management authors and clinicians have cited intentional “misbehavior” as another confounding factor in assessment of a child’s procedural distress. 15–17,24 Also, physiological distress related to hunger and the need for a nap in infants and toddlers can mimic pain behavior. To properly assess for the presence or intensity of pain, a dentist must be able to differentiate these confounding procedural behaviors from a pain behavior.
However, clinicians do not have this diagnostic capability. 25–27 In a 2018 systematic review of 50 years of research that studied clinicians’ estimation of their adult patients’ pain, 91% of the high-quality studies found that dentists, physicians and nurses all tend to underestimate their patients’ pain. 25 Adults are pragmatically used as subjects in these studies because consent is less complicated and they are regarded as reliable self-reporters. The review also found that the greater the pain intensity, as would occur when procedural distress behavior is restrained, then the greater was its underestimation. 25
It has been hypothesized that clinicians have a psychological need to rationalize away pain they cannot alleviate. 28,29 Deflecting blame for bad outcomes appears to be a tendency of human nature. 30,31 Clinicians who cause pain and are unable to effectively eliminate or reduce it may feel pressure to assign blame to other distress etiologies for their ostensible pain management failure. 11
The problem cannot be resolved by resorting to an independent, objective measure of pain. Objective, physiological measures exist, (e.g., heart rate, fMRI) but none are considered as accurate or reliable as the patient’s self-report. 33–38
Without an objective instrument to measure pain, dentists have believed that it is their responsibility to determine what pain symptoms in children are authentic and which are false. 15–17,32 In 2012, 87% of pediatric dentists who were members of the AAPD believed they had the experience and training to determine what was pain and what behavior was not pain during procedures involving tissue trauma. 32 A majority of pediatric dentists target behavior (not pain) for assessment and intervention. Fifty-two percent of pediatric dentists use a formal behavior scale such as the Frankl scale to score the intensity of negative behavior during procedures involving tissue trauma. 32 Another 32% of pediatric dentists use no formal measurement instrument to score the intensity of procedural distress behavior but likely target behavior by narratively describing a child’s behavior in the record. 32 Only 10% of pediatric dentists use a formal pain scale to measure pain intensity. 32
In 2021, 46% of pediatric dentists believe that the dentist should decide how much procedure pain a child is experiencing. 32 This does not conform to best practice recommendations in general medicine, pediatrics and nursing, which direct that the child should determine the intensity of their procedure pain. 25,39–43 When protective stabilization is used during invasive procedures, it is controlling distress movement that is identified as pain behavior by best practice recommendations, pain guidelines and established instruments of pain measurement. 25,39–44 Accepting that only the child knows how much pain they are experiencing has long been regarded as the first principle of good, clinical pain practice.
Most children ages 7 and older who are not cognitively impaired can selfreport their pain intensity using the faces pain scale. 21,22,47,48 Children under age 7 increasingly lack the cognitive development needed to discriminate between the scale points of self-report measures. 49,50 With the faces pain scale, they tend to pick end points. 21,22,49,50 For this reason, dentists, physicians and nurses must increasingly transition their method of pain assessment from a method that uses a child’s self-report of pain (e.g., revised faces pain scale 51 ) to a method that relies on observation of a child’s distress behavior (e.g., face, legs, activity, cry and consolability (FLACC) scale 44 ). When this occurs, the dentist is switching from a method of pain assessment in which the child determines the intensity of their procedure pain to a method in which the dentist decides the intensity of the child’s pain. This is how evaluator bias to underestimate pain finds its way into pain assessment methodology.
Urging dentists to use a validated pain scale is an important step in improving pain outcomes for children when they can reliably self-report their pain. But this step alone will not solve the problem of evaluator bias when dentists assess “behavior.” If a dentist who is performing an invasive procedure decides that a child’s distress behavior is not pain but some other construct such as anxiety, they will not feel the need to use a validated pain scale.
There is considerable supplementary evidence to support a best practice recommendation that instructs clinicians to treat a young child’s distress as pain when it is coincident to procedural tissue trauma until the child indicates otherwise:
■ The coincident presence of procedural tissue trauma implies that a distress behavior is a pain behavior.
■ A clinician cannot be sure that their local anesthetic has been effective. 52,53
■ Pain is subjective. 54–58 It is differentiated in each of us both genetically and environmentally by pain experience. There is no uniform pain response for a given level of tissue trauma.
■ Pain is defined as having sensory and emotional dimensions that are inextricably intertwined. The emotional dimension of pain is not a false contribution to the pain experience.
■ The needle procedures required by medical prevention protocols (vaccinations, blood draws) ensure that, by age 3, most children will perceive the dental environment as a threat environment. 65,67 Painful medical procedures (medical or dental) can classically fear/ threat condition children to any procedural environment. 57,65–67 Multiple exposures to needle pain will also result in central sensitization, which amplifies the pain experience on subsequent exposures. 68–72 The phenomenon of stimulus generalization will ensure that these phenomenon will occur in both medical and a dental environments. 74,75
■ Piaget’s discovery of “conservation errors” in reasoning in children under age 7 demonstrates that young children cannot process problems like adults. 76 Hence, they will not process threat like adults. Since the dental office is a threat environment to most children, children should not be expected to respond to a dentist’s or parent’s instructions in a threat environment (dental operatory) with the same level of compliance as they would in their home.
■ Young children have had little exposure to cultural admonitions to not show pain. Hence, they are primed to exuberantly express their pain. Generally, older children and adults tend to hide pain that is over their pain threshold but under their pain tolerance threshold. 77
■ Children can be classically fear/ threat conditioned by nonpain distress in the same manner that occurs with pain. People who get seasick (nonpain distress) are wary of boat trips. Avoiding or intervening procedural distress is a wise clinical strategy, regardless of its etiology.
■ The amygdala has the ability to associate neutral stimuli with threat (pain) on a single pairing, and there is general agreement that this learned fear can last a lifetime. 73
Practice Recommendation Two Intervene early in procedural pain behavior.
Rationale: “It is better to prevent pain than to treat it after it has occurred.” 28 If the clinician elects to intervene late in procedure pain, when distress levels are beyond the pain tolerance level of the child, then the child will experience suffering, central sensitization and classical threat conditioning in direct proportion to the intensity of their procedure pain. 56,72,78–92 The pain stimulus bell cannot be unrung.
Infantile amnesia is the general inability to recall events before age 3.5 and the decreased ability to qualitatively recall impactful events between the ages of 3.5 to age 7. 93 It would seem that infantile amnesia would protect children from the psychological harm of recalling painful, protective stabilization events that occur before age 3.5. However, infantile amnesia only effects explicit, consciously accessed memory. 94,95 If infantile amnesia affected implicit memory, children could not learn and retain the implicitly driven motor movements of walking at age 1. Because central sensitization and classical fear/threat conditioning are stored as implicit memories, 70,74 infantile amnesia will not protect against amplified pain signaling after untreated procedure pain. When these conditioned stimuli are next experienced, they will trigger an automatic fight-or-flight physiology. This can debilitate a child’s capacity to tolerate future necessary medical procedures.
Practice Recommendation Three
Choosing to not intervene in procedural pain behavior is only justified when the procedure represents the least-risk alternative.
Rationale: The assessments and judgements involved in the decision to not intervene in a child’s ostensible pain behavior is the essence of the ethical challenge inherent in the use of protective stabilization during procedures involving tissue trauma.
Procedures are justified by weighing their risks and benefits. When making this assessment, it is less complicated if the benefit is the same for all procedures. Hence, the benefit of an invasive procedure in pediatric dentistry may be reduced to the remediation, stabilization or deferral of pathology. Stabilization and deferral are equivalent benefits to full remediation because as children get older they become more tolerant of procedures. Children under age 7 generally display five times more distress during the same medical procedure than children over age 7. 56 One only need examine and compare the risks of each procedure that achieves any of these three, equivalent benefits. The goal is to find the treatment plan that entails the least risk.
One confounding element in this method is that there are differences in treatment benefits that are not necessarily valued unless these benefits are translated into risks. Full remediation of caries pathology would seem to have a greater benefit than a temporary stabilization of caries rate or temporary deferral of invasive treatment. When distal caries on a posterior tooth are remediated with a distoocclusal restoration with substantial retention features (e.g., dovetail design) and prevention features (e.g., extending margins into sound enamel), this type of restoration has greater mechanical resistance to fracture and resistance to recurrent decay than a stabilizing, transitional atraumatic restorative technique.
These variations in benefit can be translated into differences in risk. For example, the increased benefit in longevity of the more invasive restoration with retention dovetails can be translated into an increased risk of restoration failure for the less-invasive atraumatic restorative technique. However, the benefit of retention dovetails in very young, highly anxious children will generate considerable risk of negative pain sequelae due to the potentially sensitizing needle procedure that would be needed to deliver an anesthetic to alleviate pain from the more invasive prep extensions. Needle pain can turn the child’s attention on the procedure and increase their pain perception for the procedure’s duration.
Procedure pain that is over a child’s pain threshold but under their pain tolerance threshold does not need papoose-style restraints to control. Use of protective stabilization to control movement during procedures involving tissue trauma is likely restraining pain behavior that is well beyond clinical significance unless the child says otherwise. The resulting elevated levels of suffering, central sensitization and threat conditioning are difficult to ethically justify. If there is an alternate therapeutic pathway that would allow a child to be treated with reduced or no pain experience and still, in time, achieve the same benefit (remediation, stabilization or deferral), this pathway would represent the least risk alternative.
How Clinicians Decide
The examples that follow demonstrate how a clinician may decide to allow or not allow procedure pain experience to continue in children.
Note: Pain is multidimensional having both sensory and psychological dimensions. 23 In the following examples, it is always assumed that age-appropriate psychological interventions in pain (e.g., distraction and desensitization) are planned to be performed sequentially or concurrently with sensory interventions.
Example One
A 9-month-old child presents with vertical fracture of the maxillary central incisor that is through the pulp and down the root.
Treatment pathway A: Perform a less-invasive, less-pain-stimulating “transitional” procedure.
The level of procedure pain that is self-reported or observed in children decreases as they grow older. 77,104–106 A transitional procedure is one that stabilizes pathology and defers more invasive treatment until the child is older and can better tolerate procedural stimulation. However, remediation of this fracture pathology will require a very invasive, nontransitional procedure — extraction. A less-invasive procedure is just not possible for remediation, and not treating it is therapeutically unsound. Half measures would likely expose the child to two traumatic procedures: one for the half measure and one for the eventual extraction.
Treatment pathway B: Defer treatment. It may be possible to defer treatment for a short time to allow the child to unwind from their trauma, get needed sleep or eat to satisfy their hunger. Each of these physiological states in young children can cause distress during a procedure that is difficult to differentiate from a pain behavior. Pausing to eliminate them can be a useful strategy to lower variables of distress that can confound pain assessment. However, in this case, treatment cannot reasonably be deferred long enough for the child to grow, mature and develop significant pain modulating mechanisms. Therefore, this is not a viable long-term strategy. Treatment pathway C: Perform treatment under sedation or general anesthesia. More pharmacology in the form of deep sedation or a general anesthetic is associated with a very high risk in this age group. For most clinicians, this would not be acceptable.
Treatment pathway D: Perform extraction using good, local anesthetic needle technique and protective stabilization. A child this age will likely exhibit high levels of distress during both the local anesthetic needle procedure and the subsequent extraction procedure. Practice recommendation 1 compels the clinician to accept this distress as a pain behavior when tissue trauma is occurring. Thus, we may expect that treatment pathway D will result in some level of suffering, central sensitization and classical fear/threat conditioning. The extent to which this actually occurs will be evident when the child is released to the arms of their parent or caregiver. How long it takes for the child to be consoled will give some indication of the intensity of the pain they experienced during the procedure.
Despite the anticipated development of central sensitization, classical fear/threat conditioning and suffering, the stabilizing use of protective stabilization is the least risk alternative. Exposing the child to the greater risk of general anesthesia or lessinvasive treatment would have harmed the child.
Example Two
A pediatric dental sedation fails to achieve its goal of attenuating the child’s sensory and psychological dimensions of distress/pain.
Treatment pathway A: Perform less-invasive, less-pain-stimulating “transitional” procedures. If the existing caries pathology does not require extractions or pulpotomies, it may be possible to perform lessinvasive, transitional procedures and thereby avoid the risk of suffering, central sensitization and classical fear/ threat conditioning. The possibility for transitioning to a less-invasive treatment plan should be discussed during the sedation consent process. The need to monitor and maintain a less-invasive treatment pathway should be included in the consent process. This treatment option requires a prudent frequency of observation and, when needed, repair of transitional restorations and reapplication of noninvasive measures.
Because clinicians cannot know the unique pain tolerance threshold of any child, the primary task of a pediatric dentist is to not perform any invasive procedure that can reasonably be deferred. Clinicians may choose to err on the side of caution and repeat less-invasive, 111–113 stabilizing or noninvasive 114–116 deferral procedures until the primary tooth exfoliates or until the child ages to procedural tolerance.
Treatment pathway B: Defer treatment. This is usually performed on selected carious lesions in tandem with treatment pathway A. It always includes the use of mineralizing agents (e.g., fluoride varnish, silver diamine fluoride) to slow or reverse the rate of the decay.
Treatment pathway D: Abort the sedation and reschedule with general anesthesia at a later date. This treatment pathway may be the least-risk alternative when there are extensive and deep caries that rule out less-invasive treatment alternatives.
Future novel interventions in caries or tooth fracture may change the risk that is associated with remediating, stabilizing or deferring these pathologies. The value assigned to each component of risk will vary from clinician to clinician. Each clinician has differences in skill, experience and education. Each clinician will have their favored procedures to achieve the same benefit. The previous examples have been designed to reduce ambiguity and variance in the clinician’s estimation of risk. As the child grows older and the clinical conditions become less sharply defined, clinician differences in the assessment of risk are more likely to come into play. When this happens, clinicians may take different clinical paths to achieve the same least-risk outcome for the pediatric patient. However, practice recommendation 1 will prohibit clinicians from downwardly revising the intensity of a child’s behavioral expression of pain in order to justify a procedure.
Conclusions
■ Many pediatric dentists practice a method of procedure pain assessment that does not conform to best practice recommendations.
■ Until an accurate, reliable, clinically useful and objective measure of pediatric procedure pain is found, distress behavior that occurs coincident with procedural tissue trauma is pain behavior until the child says otherwise.
■ Intervene early in procedural pain behavior.
■ Choosing to not intervene in procedural pain behavior is only justified when the procedure represents the least-risk alternative. n
