19 minute read
Pain, Psyche and Protective Stabilization
Paul S. Casamassimo, DDS, MS; Beau Meyer, DDS, MPH; and Janice A. Townsend, DDS, MS
ABSTRACT
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Background: Protective stabilization (PS) and its subset of medical immobilization (MI) with a passive device have been part of advanced behavior guidance in pediatric dentistry for decades, yet they remain controversial. Inadequate evidence on risks and benefits, ambiguous indications and newer societal and professional skepticism make application of these techniques the subject of continuing debate. PS and MI are often the treatments of last resort and can be effective and safe.
Conclusions: Clinical, psychological and logistic considerations should guide clinicians when these techniques are among behavior guidance choices. Like other forms of advanced behavior guidance, PS and MI affect children and family, and their application is also shaped by the community and care system.
Practical implications: Professional guidelines provide general directions for use of PS and MI, and these should be refined by the clinician’s recognition of the limitations and possible effects of use. Finally, in the absence of a clear evidence-based pathway, application of a logic algorithm can both maximize the benefit of PS and MI and minimize negative outcomes.
Keywords: Behavior, pediatric dentistry, safety, medical immobilization, protective stabilization
AUTHORS
Paul S. Casamassimo, DDS, MS, is a professor emeritus at The Ohio State University College of Dentistry and an attending dentist at Nationwide Children’s Hospital in Columbus, Ohio. Conflict of Interest Disclosure: None reported.
Beau Meyer, DDS, MPH, is an assistant professor at The Ohio State University College of Dentistry, division of pediatric dentistry and is on the medical staff at Nationwide Children’s Hospital in Columbus, Ohio. Conflict of Interest Disclosure: None reported.
Janice A. Townsend, DDS, MS, is the chief of pediatric dentistry at Nationwide Children’s Hospital and the chair of the division of pediatric dentistry at The Ohio State University College of Dentistry. Conflict of Interest Disclosure: None reported.
Editor’s Note: This article is a companion to “How Do We Protect a Child’s Psychological Health During Procedures That Use Protective Stabilization?” on page 453.
The use of protective stabilization (PS) must consider the overall health and safety of the pediatric patient as the highest priority. Consideration of important ethical and pragmatic consequences is integral to proper application of PS. Paying attention to pain management, maintaining patient safety, providing quality dental care and protecting the developing psyche are assumed in every application of PS and essential to the decision-making process when choosing to use PS.
The umbrella of PS includes active stabilization by the parent or dental team as well as passive stabilization with an immobilization device that we will refer to as medical immobilization (MI). While most PS in pediatric dentistry is limited to hand guarding and head stability, the term immediately conjures up the image of a papoose board. It should escape no one that MI remains controversial. Unlike the hand-over-mouth technique (HOM), MI remains in our guidelines and in the acceptable practice of pediatric dentistry, as it does in medical care. MI has been reshaped by societal, safety and ethical shifts as well as advances in other pharmacologic forms of behavior guidance. Its place in our therapeutic toolkit has admittedly narrowed, yet MI remains an indicated behavior guidance tool in some clinical situations. The growing difficulty in obtaining operating room access for dental care 1 and changing state laws potentially restricting in-office moderate sedation 2 in the U.S. suggest that MI will remain in pediatric dental health care for the foreseeable future.
This paper briefly reviews the role of MI and PS, offers qualifiers before their use, builds on some of the concepts in Dr. Dennis Paul Nutter’s article in this issue, suggests an algorithm for application of PS in today’s pediatric dentistry environment and offers illustrations of PS and MI use or better-advised alternatives.
Evolution of PS Using MI
The terms protective stabilization (PS) and medical immobilization (MI) are often used interchangeably, but MI is the use of a temporary protective stabilization device indicated when alternatives may not be available, not timely or not the best choice. Before sedation and general anesthesia became more common, MI filled a void as dentists attempted to improve safety and technical quality and increase the chances of treatment completion. As with many forms of behavior guidance in dentistry, MI has been, until recently, provider- rather than patient-centered. Dr. Nutter’s article offers a useful 180-degree perspective long overdue. Interestingly, unlike pediatric sedation, MI lacks rigorous evaluation using today’s tri-factorial definition of behavior guidance success: safety, efficacy and long-term impact. The accumulated references and literature basis for MI are outdated, testimonial in nature and largely lacking clinical data. 1 In medicine, use of restraint for general behavior management of patients with intellectual disability or behavior disorders has been shaped by a decades-long recognition of institutional abuses, mental health inequities and wider availability of alternatives. In contrast to general restraint, MI is typically a single episode limited to the time needed for a procedure, and the short-term and long-term effects of MI in dentistry are simply unknown and can only be surmised. Guidelines and decision tools do exist 2,3 and are improved regularly but still lack high-quality evidence and would be best described as expert opinion. Strong evidence remains elusive.
A Realistic View of MI
The context of MI use has changed from a generation ago. The Fisher-Owens et al. 4 conceptual model of caries initiation is surprisingly useful in delineating the contextual environment in which a provider today decides to use MI:
■ The child. Dr. Nutter’s paper lays out a variety of little understood potential effects of PS on a child, ranging from fear to residual impact on the developing psyche to central pain sensitization. In a patientcentered model, these risks, even without supporting data, take center stage as the dentist weighs risks and benefits along with medical necessity when deciding to use MI.
■ The family. Often only involved in consent issues by the dentist, little is known about the psychological effects of MI use on parents. Parents must juggle a complicated set of factors: The medical necessity of the procedure, their innate desire to protect their child, the child’s previous or potential response to MI, their own dental anxiety and history, their feelings and emotions related to their role in the presenting problem and, in some cases, spousal disagreement and limited resources for other choices. In short, consent for MI is not simple. On the other hand, the dentist should consider the implications of withholding this modality, especially from a family facing barriers to care when the dental procedure completed using MI may eliminate unnecessary pain or suffering. If providers exclude patients in poverty from their practice, they may have the luxury of easy access to general anesthesia. However, these providers must acknowledge the barriers that patients who are uninsured or have public insurance face and recognize that MI may be the compassionate choice for these children.
■ The community. In our more diverse world, dentists are challenged to understand still another potential conflict within today’s health care where professional and patient perspectives can collide. Townsend et al. 5 recently documented the mosaic of opinion about PS/ MI across the world. Stoicism, dental fatalism, religious aspects of physical contact and other issues all can impact the acceptability of MI. The reputational risk of accusations of misuse of MI might further limit use of this technique.
■ The system. Our health care system impacts use of MI in various ways. Regulatory bodies may inadvertently increase its use by limiting availability or practicality of certain pharmacological behavior guidance options. 6 Conversely, they may discourage its use through heightened oversight resulting from parental complaints to licensure bodies. Alternatives to MI are often more expensive and sometimes inaccessible, particularly in the case of long waitlists for general anesthesia. Understandably, MI persists in situations where it may not be the ideal choice due to regulatory, financial and access barriers.
The above builds on Dr. Nutter’s article’s admonition that application of MI isn’t simply a checklist based on professional guidelines, but a far more complex decision, using professional guidelines more as guardrails than guidance. It is not, nor should it be, a simple decision to use MI. The best preparation for safe, compassionate and effective application of MI would be to internalize the previous four concepts influencing the decision to use MI and any advanced behavior guidance tool. Having a flexible clinical pathway to a sound, sensitive and effective decision should be the ideal, with potential pitfalls identified early and discussed during the consent process if possible.
Aiming for Superlatives
The following terms describe when, where and how to use PS, and these terms should shape clinicians’ decisions to use it and what form it should take. These include:
■ Gentlest. Protective stabilization prompts images of a pedi-wrap or papoose board, but the literature provides numerous examples ranging from sheets and blankets to staff and parental engagement with their relief and satisfaction. 7,8 Children with autism spectrum disorder may benefit from MI 8 and report comfort from weighted coverage like a lead apron used for radiographs. The least invasive and least traumatizing technique should be employed. Gentleness conceptually may mean adjunctive emotional support rather than just physical contact.
■ Shortest. It should be assumed that PS is a later choice on the behavior guidance continuum and that attention to principles proposed in this and Dr. Nutter’s article would limit the length of time PS is used. Medical application of PS is often monitored in increments of 15 to 20 minutes and limited to one hour without review, 10 which presumes reevaluation of all aspects of its choice before continuation. For many children, MI can be removed after the procedural step with the highest risk for harm, such as the local anesthesia injection or the final delivery of an extracted tooth, is completed.
■ Safest. Media reports of broken bones, dislocated joints and bruising have highlighted supposed extremes of PS. 11,12 Potential psychological and emotional concerns described in Dr. Nutter’s article are likely tied to potential physical side effects. The examples at the end of this article speak to choices around PS that consider the range of safety.
■ Rarest. The American Academy of Pediatric Dentistry (AAPD) defines PS as an advanced behavior guidance technique. 2,3 Inherent in the continuum of intensity of behavior guidance techniques is that basic tools like communication, distraction and tell-show-do are applied in nearly every patient encounter, whereas advanced tools like sedation or general anesthesia are used in special circumstances. PS may be erroneously assumed to be on a continuum, suggesting its frequency is more than pharmacologic. In truth, PS is really meant to be a deadend tangent relegated, as suggested in this article, to situations when either simple or more advanced techniques are not options.
An Algorithm for Safe and Necessary Use of PS
The proposed algorithm (FIGURE) builds on those of Meyer et al. 13,14 for treatment decisions and adds elements both pre- and post-PS application. Readers are encouraged to look at other algorithms that help guide clinicians through treatment decisions that require balancing medical necessity for a given clinical presentation with behavior guidance guidelines in a potentially emotional real-time crucible.
To build on principles in Dr. Nutter’s article, we posit the following additional principles that are meant to be useful clinically.
■ Establish medical necessity. A valuable insight from Dr. Nutter’s article is that PS is an advanced technique and one that should not be used routinely. Media accounts and dental board complaints about MI being abused for financial purposes 15 should be enough to convince anyone that PS is not intended for routine care. Defining medical necessity in nonlife-threatening scenarios balances potential risk with common sense. For example, the case of a child or adolescent with autism whose status can only be assessed with PS likely benefits from PS. By using PS for the examination, the dentist can determine whether alternative advanced behavior guidance is needed. That scenario is commonplace in pediatric dental practice.
■ Assess the likelihood of treatment completion or achievement of stability. PS can be an appropriate option in cases where treatment needs to be completed for the child to reach a point of stability. The concept of treatment completion includes managing untoward events during or following a procedure as well as minimizing need for subsequent treatment. A few examples of the previous criteria in pediatric dentistry would be the ability to manage postoperative bleeding complications after a PS-supported tooth extraction (achievement of stability) or choosing to defer completing tooth restoration following a pulp procedure on a primary tooth (treatment completion) requiring an additional treatment session perhaps unnecessarily.
■ Determine timely alternatives. PS should be the last resort for treatment that cannot wait and for which no alternative advanced behavior guidance technique is available within a reasonable time frame. Some dentoalveolar trauma can wait and delay may not affect outcomes, such as in a complicated crown fracture of a permanent tooth. In some clinical situations, an antibiotic course may allow better access, more effective local anesthesia and a less painful procedure later.
■ Prepare for possible outcomes, expected or otherwise. Treatment may become more complicated, parental consent may change after viewing the reality of care unfolding, an untoward event may occur, a parent may faint or a child may experience a medical issue. While it isn’t always possible to prepare for every contingency or complication, a pathway for dealing with unexpected outcomes during and/or as the result of PS should be established before using it. Importantly, if parental consent changes, the provider and parent should have a clear understanding before beginning the procedure of what constitutes “the point of no return” – the stage at which treatment must be completed for that patient.
■ Assess child and parent status frequently. The concept of continuous monitoring during PS has not become as widespread in dentistry as in medicine. As with all other advanced behavior guidance techniques, like sedation or general anesthesia, good practice of PS dictates frequent evaluation of child fear, pain, physiologic status and parental response. In medical application of PS, usually at 15- to 20-minute intervals, the process is assessed for safety and efficacy and often needs to be reassessed by a physician after these status checks.
It is unlikely that regular recording of status at short intervals will soon become standard or practical. These progress checks likely occur as an internal informal process with dental staff, which is then described in the patient record treatment note postoperatively. Quality and safety steps, such as procedural timeouts and procedure completion status, should also be a part of a PS episode, due to its intensity, and recorded.
■ Account for after-visit care prior to initiation of PS. If circumstances around dental treatment mandate PS, it is prudent to consider aftercare and the difficulties caretakers might encounter in managing healing and homecare procedures. Standard postoperative instructions may fall short. The failure to account for postoperative pain, cooperation and other aspects of aftercare can cause problems that range from irritating to catastrophic. Postoperative instructions should include debriefing about the child’s reaction to PS as well as the parents’ feelings about what transpired. A discussion would also entail next steps and how to approach future dental visits. As indicated in the algorithm, future visits might entail some alternate form of advanced or basic behavior guidance. Use of the memory restructuring behavior guidance technique to help the child cope with a difficult appointment can promote coping and minimize dental fear.
Some Experiences From the Field
Many pediatric dentists will have both poignant and humorous recollections of PS, and we felt it might be instructive to give case examples from our own experiences, some as recent as the writing of this article and some from the past, and our reflections on what transpired.
Case One
A 17-month-old child with a vertical complicated crown root fracture on tooth E would not nurse or eat due to pain. She had the tooth extracted with local anesthesia while restrained in a papoose board with mother holding her hand and in sight. Mother declined knee-to-knee treatment due to her own anxiety. The child was engaged and happy at her one-week follow-up.
A host of factors played into use of MI, not the least of which was a worried young mother unsure of her ability to help and a very young child who would not eat. Her age and weight made general anesthesia the only other advanced behavior guidance option, but her age was also a factor in deciding that this event would be lost in the comfort of her mother’s arms and soothing voice immediately after treatment.
Case Two
A 10-year-old boy with an abscessed maxillary second primary molar and week-long pain refused treatment in spite of parental firmness to do so. The father exited the operatory in frustration. The pediatric dentist offered basic behavior guidance if the child would be cooperative, but said he would “bring in the muscle” to hold him if needed, pointing to an athletically built resident and staff member. The boy uttered, “No muscle, no muscle,” cooperated for care, which was uneventful, and was praised by staff and his parent as he left smiling, proud of his courage, with his tooth to brag on with his friends.
The wisdom of “good cop/bad cop” is one played out often in pediatric dentistry. For this boy on the cusp of puberty, this decision was probably a hard one, but one that demonstrated a small step toward maturity. In this case, PS was not used and the outcome was a win-win for all.
Case Three
The mother of an 8-year-old girl with multiple developmental delays requested MI for a periodic exam and cleaning. The child screamed throughout the procedure. The dental resident periodically checked in with the mother during the procedure and constantly consoled the child. The young mother was adamant that her daughter “get used to” her frequent health care experiences, including dental care, and said PS is a regular part of many health care visits. Mom rewarded her daughter with praise and reassurance and the dental staff did as well.
Unless you live every day with a child with special health care needs, as this single mother does, it is hard to argue that her operant conditioning leading to an acceptance of life’s realities was a bad thing. In this case, MI was employed effectively for routine preventive care. At some point, hopefully, this child will say she does not need PS and will enjoy the satisfaction of accomplishment on her own terms.
Case Four
A 17-year-old with significant intellectual disability sat in the backseat of a car after she and her family traveled several hundred miles through the night to find a dentist to treat her pain. She refused to leave the car. The dentist asked her family to help restrain and comfort her while removing the offending tooth in the car under local anesthesia. Ten minutes postoperatively, the teen was laughing and walking hand-in-hand with her mother in the parking lot.
This may be as unorthodox a case of PS as exists, but 40 years ago, there weren’t many good alternatives. The dentist clearly read the family’s despair, the child’s fear and the child’s inability to cooperate before engaging the family in the best way possible. The power of love and caring by family and provider may be the best psychological salve we can call on when PS is needed.
Case Five
A 10-year-old boy with autism had done well with tell-show-do and other basic behavior guidance in previous visits, but today was pacing and clearly agitated. Using a camping and sleeping bag metaphor to explain the papoose board, the dentist completed restorative treatment under local anesthesia and the boy was perfectly still throughout the appointment and left smiling.
This successful use of MI brought together advanced and basic behavior guidance to achieve positive emotional and dental outcomes. It was both ethical, clever and consistent with behavioral guidelines to relate MI to familiar positive experiences and administer it with the overlay of ongoing communicative behavior guidance. Imagery like seat belts, burritos, snuggling, car seats and other positive associations have all been used to desensitize children for MI.
Case Six
An obese 16-year-old teenager with significant intellectual disability was seen on emergency for dental pain and cellulitis and placed, with assistance from the parents and several staff, into a large papoose board on a reclined dental chair.
Her negative and violent reaction early in the experience caused her to struggle to escape and ended with her, still wrapped, falling off the chair, being bruised and then traveling to an emergency department for physical examination for injury and treatment of the offending tooth.
The lesson here may be no good deed goes unpunished, think twice before you act or both. The better approach might have been to use the child’s trust of her parents to gain a view of the dental situation and then consider available options. Physical injury with ill-advised MI or PS is always a risk to be considered a priori at any age.
Summary
The decision to complete dental treatment with protective stabilization is often a marriage of psychology and surgery, where decision-making balances both seen and unseen psychological trauma with medically necessary treatment. Use of PS and MI in dentistry has undoubtedly at times been inappropriate, resulting in harm to children and the profession’s image, but also been successful in reducing pain and suffering, with no untoward short- or long-term effects. Every tool in the pediatric dentist’s toolbox has potential for abuse, whether it be unsafe in-office sedation, inappropriate use of stainless-steel crowns or overuse of general anesthesia. The profession should not discard a modality based on risk of abuse alone and should test its safety and utility through the use of guidelines based on evidence and clinical research and practice. It is doubtful that PS will leave our armamentarium soon nor would that be desirable as it allows us another care option, after weighing its risks and benefits. Greater awareness of its possible effects and potential risks serves both patients and providers well. This article and Dr. Nutter’s should help set a practitioner’s compass in caring for those challenging patients for whom PS and MI may be the best or worst choice of behavior guidance. n
