(a)Parent or Guardian. In this section
the term "parent or guardian" refers to one of the following:
(1)the natural or biological father or mother of a
child with full parental legal rights;
(2)a custodial parent who in the case of divorce has
been awarded legal custody of a child;
(3)a person appointed by a court to be the legal guardian
of a minor child; or
(4)a foster parent - a non-custodial parent caring
for a child without parental support or protection who was placed
by local welfare services or a court order.
[(a)The Texas State Board of Dental
Examiners utilizes the "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)Applicability. This section applies
to the use of protective stabilization when treating pediatric and
special needs patients.
(1)For purposes of this section a "knee-to-knee examination"
during which the dentist and the patient's parent or guardian put
knees together to create a "dental chair" is not considered protective
stabilization. A knee-to-knee exam does not use any apparatus or equipment
to restrain the patient and does not involve the use of dental personnel
other than the treating dentist.
(2)Although a mouth prop may be used as an immobilization
device, the use of a mouth prop in a compliant child is not considered
protective stabilization for purposes of this section.
(c)[(b)] Purpose. Infants,
children, adolescents, and patients with [Pediatric and]
special health care needs [patients] may require
protective stabilization [specialized case management]
to prevent injury and protect the health and safety of the patient,
practitioner, and staff, and to safely expedite emergency treatment
for a pre-cooperative child, uncooperative child, or patient with
special health care needs if it is deemed necessary for the long-term
health of the patient. The goals of protective stabilization
as a part of individualized patient behavior guidance [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. Protective [In addition to patient
management, it may be necessary to use protective] stabilization
is an advanced behavior guidance technique in dentistry that can be
used for treatment involving pediatric and special needs patients.
(d)[(c)] Protective Stabilization.
[(1)Protective stabilization is considered
an advanced behavior guidance technique in dentistry.]
(1) [(2)] Protective stabilization
is the physical limitation of a patient's movement by a person,
restrictive equipment, materials or devices for a finite period of
time [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 immobilization [stabilization],
which involves the physical limitation of movement [restraint
] by another person, such as the parent or guardian,
dentist, or dental auxiliary; and
(B)passive immobilization, which utilizes a restraining
device.
(2)[(3)] Protective stabilization
shall not be used as a means of discipline, convenience, or retaliation.
Protective stabilization shall not be used for "routine," non-emergent
treatment needs or in order to accomplish full mouth or multiple quadrant
dental rehabilitation. Protective stabilization shall cause
no serious consequences, such as physical or psychological harm, loss
of dignity, or violation of the patient's rights. It is the responsibility
of the treating dentist and the dental team to guard against these
aforementioned outcomes.
(3)[(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.
(4)[(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.
(5)[(6)] Informed Consent.
(A)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 and utilization of protective stabilization.
Written informed consent should be documented in the patient's records.
(B)Informed consent shall include an explanation
, by the treating dentist, of the benefits and risks of protective
stabilization, alternative behavior guidance techniques, and a clear
explanation of the anticipated protective stabilization techniques
to be used, including the possible use of restraining devices,
and a statement that a parent or guardian may revoke informed consent
for protective stabilization at any time.
(C)If possible, the treating dentist
should obtain informed consent for protective stabilization on a day
separate from the treatment requiring protective stabilization.
(D)If the patient's behavior during
treatment requires a change in the protective stabilization, separate
informed consent must be obtained and documented.
(E)When providing dental care for
adolescents or adults with mild intellectual disabilities, patient
assent for protective stabilization should also be considered. Informed
consent should take into account the patient's feelings towards the
use of protective stabilization. A conditional comprehensive explanation
of the technique to be used and the reasons for application should
be provided.
(F)A parent or guardian may revoke
informed consent for protective stabilization at any time if they
believe the patient may be experiencing physical or psychological
trauma due to immobilization.
(6)[(7)] Parental or Guardian
Presence. The treating dentist [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.
(7)[(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.
(8)[(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 while maintaining blood flow and respiration;
(D)specifically designed for protective stabilization;
and
(E)ability to be disinfected.
(9)[(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)urgent [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 protect the patient's safety and help
to expedite completion of treatment [reach a safe stopping
point];
(D)a sedated patient requires limited stabilization
to help reduce untoward movements during treatment [becomes
uncooperative during treatment];
(E)an uncooperative patient requires
limited treatment and sedation or general anesthesia may not be an
option because the patient does not meet sedation criteria, there
is a long operating room wait time, financial considerations, and/or
parental or guardian preferences after other options have been discussed;
or
(F)[(E)] a patient with special
health care needs exhibits [for whom] uncontrolled
movements that would be harmful or significantly interfere
with the quality of care.
(10) [(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;
or[.]
(E)the dentist's convenience.
(11)[(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 monitoring during
stabilization;
(G)any adverse outcomes, such as bruising or skin
markings; and
(H)management implications and plans for future appointments.
(12)Patients with Special Health
Care Needs.
(A)Children and adolescents with special health care
needs will at times require protective stabilization to facilitate
completion of necessary dental treatment. Aggressive, uncontrolled,
and impulsive behaviors along with involuntary movements may cause
harm to both the patient and dental personnel. Use of protective stabilization
reduces potential risks and provides safer management of patients
with special health care needs. When considering protective stabilization
during dental treatment for special health care needs patients, the
dentist in collaboration with the parent or guardian must consider
the importance of treatment and the safety consideration of the restraint.
(B)The dentist should be cautious when utilizing protective
stabilization on children and adolescents receiving multiple medications.
The propensity of adverse central nervous system or cardiac events
occurring may increase when protective stabilization is instituted
on patients receiving psychotropic or other medications.
(C)The dentist should consider utilizing alternative
behavioral approaches to reduce movement and resistance as well as
increasing cooperation when proving medically necessary dental care
for patients with special health care needs prior to implementing
protective stabilization, such as:
(i)distraction via counting, positional modeling,
and repetitive tasks and visits;
(ii)shaping;
(iii)modeling;
(iv)sensory integration;
(v)desensitization;
(vi)reinforcement; or
(vii)non-pharmacological behavior guidance approaches
by skill training in acceptable behaviors in the dental operatory.
(e)[(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 25, 2019
TRD-201900877 Alex Phipps
General Counsel
State Board of Dental Examiners
Earliest possible date of adoption: May 5, 2019
For further information, please call: (512) 305-9380
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