(a) The Texas State Board of Dental Examiners utilizes
the "Guideline on Protective Stabilization for Pediatric Dental Patients"
published in the American Academy of Pediatric Dentistry in determining
the standard of care for protective stabilization used in dentistry.
(b) Pediatric and special needs patients may require
specialized case management to prevent injury and protect the health
and safety of the patient, practitioner, and staff. The goals of patient
management are to establish communication throughout dental care;
alleviate fear and anxiety; deliver quality dental care; build a trusting
relationship between the patient, parent or guardian and the dental
professionals; and promote the patient's positive attitude toward
dental care. In addition to patient management, it may be necessary
to use protective stabilization for treatment involving pediatric
and special needs patients.
(c) Protective Stabilization.
(1) Protective stabilization is considered an advanced
behavior guidance technique in dentistry.
(2) Protective stabilization is any manual method,
physical or mechanical device, material or equipment that immobilizes
or reduces the ability of a patient to move his or her arms, legs,
body or head freely. Two types of protective stabilization are:
(A) active stabilization, which involves restraint
by another person, such as the parent, dentist, or dental auxiliary;
and
(B) passive immobilization, which utilizes a restraining
device.
(3) Protective stabilization shall cause no serious
consequences, such as physical or psychological harm, loss of dignity,
or violation of the patient's rights.
(4) Training Requirements. A dentist utilizing protective
stabilization shall have completed advanced training either through:
(A) an accredited post-doctoral program or pediatric
dentistry residency program that provides clinical and didactic education
in advanced behavior management techniques; or
(B) an extensive and focused continuing education course
of no less than 8 hours in advanced behavior management that includes
both didactic and clinical education pertaining to Protective Stabilization.
(5) Practitioner Supervision. The dentist shall not
delegate the use of protective stabilization to the dental staff,
but they may assist the dentist as necessary.
(6) Consent. Protective stabilization requires written
informed consent from the parent or guardian which should be obtained
separately from consent for other procedures to ensure parent awareness
of the procedure. Informed consent shall include an explanation of
the benefits and risks of protective stabilization, alternative behavior
guidance techniques, and a clear explanation of the anticipated restraining
devices.
(7) Parental or Guardian Presence. Practitioners should
consider allowing parental or guardian presence in the operatory or
direct visual observation of the patient during use of protective
stabilization unless the health and safety of the patient, parent,
guardian, or dental staff would be at risk. If parents or guardians
are denied access, they must be informed of the reason with documentation
of the explanation in the patient's chart.
(8) Pre-Stabilization Considerations. Prior to utilizing
protective stabilization, the dentist shall consider the following:
(A) alternative behavior management methods;
(B) the dental needs of the patient and the urgency
of the treatment;
(C) the effect on the quality of dental care during
stabilization;
(D) the patient's comprehensive, up-to-date medical
history;
(E) the patient's physical condition, such as neuromuscular
or skeletal disorders; and
(F) the patient's emotional development.
(9) Equipment. The restraining devices used for dental
procedures should include the following characteristics:
(A) ease of use;
(B) appropriately sized for the patient;
(C) soft and contoured to minimize potential injury
to the patient;
(D) specifically designed for protective stabilization;
and
(E) ability to be disinfected.
(10) Indications. Protective stabilization is indicated
when:
(A) a patient requires immediate diagnosis and/or urgent
limited treatment and cannot cooperate due to emotional and cognitive
developmental levels, lack of maturity, or medical and physical conditions;
(B) emergent care is needed and uncontrolled movements
endanger the patient, staff, or dentist;
(C) treatment is initiated without protective stabilization
and the patient becomes uncooperative, causing uncontrolled movements
that endanger the patient, staff, or dentist, and protective stabilization
will enable the dentist to reach a safe stopping point;
(D) a sedated patient becomes uncooperative during
treatment; or
(E) a patient with special health care needs for whom
uncontrolled movements would be harmful or significantly interfere
with the quality of care.
(11) Contraindications. Protective stabilization is
contraindicated for:
(A) cooperative, non-sedated patients;
(B) patients who cannot be immobilized safely due to
associated medical, psychological, or physical conditions;
(C) patients with a history of physical or psychological
trauma due to restraint; and
(D) patients with non-emergent treatment needs in order
to accomplish full mouth or multiple quadrant dental rehabilitation.
(12) Documentation. In addition to the record requirements
in §108.8 of this title (relating to Records of the Dentist),
the patient records shall include:
(A) indication for stabilization;
(B) type of stabilization;
(C) informed consent for protective stabilization;
(D) reason for parental exclusion during protective
stabilization (when applicable);
(E) the duration of application of stabilization;
(F) behavior evaluation/rating during stabilization;
(G) any adverse outcomes, such as bruising or skin
markings; and
(H) management implications and plans for future appointments.
(d) Deferred Treatment. Treatment deferral or discontinuance
shall be considered in cases when treatment is in progress and the
patient's behavior becomes hysterical or uncontrollable. In such cases,
the dentist shall halt the procedure; discuss the situation with the
parent or guardian; and either select another approach for treatment
or defer treatment based upon the dental needs of the patient. Upon
the decision to defer treatment, the dentist shall immediately complete
the necessary steps to bring the procedure to a safe conclusion before
ending the appointment. A recall schedule shall be recommended after
evaluation of the patient's risk, oral health needs, and behavior
abilities.
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