Texas Register

TITLE 22 EXAMINING BOARDS
PART 5STATE BOARD OF DENTAL EXAMINERS
CHAPTER 108PROFESSIONAL CONDUCT
SUBCHAPTER APROFESSIONAL RESPONSIBILITY
RULE §108.14Pediatric and Special Needs Case Management; Protective Stabilization
ISSUE 03/28/2014
ACTION Proposed
Preamble Texas Admin Code Rule

(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.

  (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 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 includes an explanation of the benefits and risks of protective stabilization, as well as 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;

    (D)a sedated patient may become 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 22 TAC §108.8, 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.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on March 13, 2014

TRD-201401159

Sarah Carnes-Lemp

General Counsel

State Board of Dental Examiners

Earliest possible date of adoption: April 27, 2014

For further information, please call: (512) 475-0977



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