JCTXXX10.

1177/2380084420963933JDR Clinical & Translational ResearchPerception of Protective Stabilization by Pediatric Dentists

research-article2020

Vol. XX • Issue X Perception of Protective Stabilization by Pediatric Dentists

Original Report: Qualitative Research

Perception of Protective Stabilization

by Pediatric Dentists:
A Qualitative Study
M. Marty1, A. Marquet1, and M.C. Valéra1,2

Abstract: Introduction: Pediatric Results: This analysis highlighted or the medical team), while showing its
dentists sometimes have to care for 3 main themes. First, the perceptions psychological impact on practitioners.
children who refuse to cooperate of dentists concerning protective Finally, this work provides a basis for
with the oral examination or dental stabilization showed that this decision makers to propose a framework
treatment. Behavior management procedure has a major psychological for the use of physical restraint.
strategies are used, such as “tell- impact and led to a feeling of
Keywords: physical restraint, pediat-
show-do,” distraction, and professional failure. Second, the
ric dentistry, dental care, psychological
positive reinforcement. Anxiety reasons for which the child was
impact, child, anxiety management, qual-
management can also be performed stabilized were described; these
itative study
by the use of conscious sedation (oral concerned the child (behavior, age,
premedication, nitrous oxide/oxygen number of treatments) and the
inhalation). Unfortunately, these environment (the parents and the Introduction
techniques are sometimes insufficient medical team). Finally, we detailed
Behavior guidance techniques,
for providing oral care, and protective how dentists manage the effects of
nonpharmalogic and pharmalogic, are
stabilization may be an option in using of protective stabilization.
used to alleviate anxiety and perform
some situations. Little is known on Conclusion: Dental surgeons quality oral health care safely and
the impact of physical restraint and must balance their requirement to efficiently for children and persons with
how practitioners feel about it. The make concrete decisions regarding special health care needs. The American
objective of this study was to evaluate the provision of care with their Academy of Pediatric Dentistry (AAPD;
the perception of dentists using personal convictions about protective 2017) summarizes the basic behavior
protective stabilization for dental care stabilization. This study also shows guidance techniques, such as “tell-
in children. the need for specific training on show-do,” voice control, nonverbal
Methods: Semistructured qualitative this subject, as well as the desire of communication, positive reinforcement,
interviews on the perception of certain dentists that public authorities distraction, parental presence/absence,
pediatric dentists concerning protective implement legislation on this matter. memory restructuring, and nitrous oxide/
stabilization were conducted in the Knowledge Transfer Statement: oxygen inhalation. Advanced behavior
pediatric dentistry department of The findings of this study will improve guidance techniques include protective
the University Hospital of Toulouse, the management of young patients by stabilization, sedation, and general
France. A thematic analysis of identifying situations where protective anesthesia. “Behavior guidance is as
interview transcripts was provided via stabilization may be useful (age of the much an art as it is a science” (AAPD
NVivo software. child, diagnosis, protection of the child 2017), and these techniques must be

DOI: 10.1177/2380084420963933. 1Faculté de Chirurgie Dentaire, Université de Toulouse III, Toulouse, France; 2Inserm, U1048 and Université Toulouse III, I2MC, Toulouse,
France. Corresponding author: M.C. Valéra, Faculté de Chirurgie Dentaire, Université de Toulouse III, avenue Jean Poulhes, CHU Rangueil, 31432 Toulouse, France.
Email: marie.valera@inserm.fr

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© International & American Associations for Dental Research 2020
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 JDR Clinical & Translational Research
integrated into an overall behavior
guidance approach that is individualized
for each child.
When behavioral and pharmaceutical
techniques do not work, practitioners
may use protective stabilization.
Protective stabilization is the term
used in dentistry for the restriction of
a patient’s freedom of movement by
a person or by restrictive equipment
for a finite period, with or without
the permission of the patient, to
decrease risk of injury while allowing
examination, diagnosis, and/or
treatment. Some scientific societies
have proposed a framework for the
use of physical restraint. For instance,
the AAPD recently adopted a guideline
regarding the use of protective
stabilization in pediatric dentistry in the
United States (AAPD 2017). The Scottish
Intercollegiate Guideline Network
has stated since 2002 that there is no
place for restraint during dental care in
children (Nunn et al. 2008). In France,
the National Authority for Health has
published numerous recommendations
for pediatric dentistry, such as strategies
for the prevention of tooth decay
or the use of fluorides, but there is
no guideline concerning the use of
protective stabilization.
Despite the lack of recommendation,
the use of chemical and physical
restraint in geriatrics and psychiatry
is widely documented, and the most
frequently cited goal is the prevention
of injury that could be inflicted onto
patients (Mahmoud 2017; Zulfiqar
et al. 2018). The literature on this topic
in pediatrics focuses on the restraint
used to perform a specific medical
procedure, such as emergency care
(Connick et al. 2000; Lombart et al.
2019). Pediatric dentists can use physical
restraint when behavior management
techniques fail. This decision may have
repercussions on children and parents,
but the health care team is also affected.
The perception of physical restraint
by pediatric dentists has been poorly
studied. A study conducted among
members of the AAPD reported that 73%
of responding practitioners use physical
2
restraint (Adair, Waller, et al. 2004).
Another study concerned teaching in
pediatric dentistry, and it showed that
91% of postdoctoral programs offer
protective stabilization as an acceptable
technique for caring for children (Adair,
Rockman, et al. 2004). In addition, the
use of protective stabilization by dental
surgeons depended on their age and
training because the philosophy of the
education received would influence
the practice of this technique (Peretz
and Gluck 2002). Connick and Barsley
(1999) reported that 66% of dental care
at a center for disabled children in
Louisiana was achieved with the help of
protective stabilization, and they argued
that otherwise these children would
have had poorer oral health. O’Donnell
(1994) questioned the concept of “right
to health” in patients with specific needs
and denounced, in turn, barriers that
would contribute to the deterioration
of their state of dental health by
stigmatizing the use of restraints in this
population. Thus, although physical
restraint appears to be widely used by
dentists around the world, the impact
of this technique on practitioners has
hardly been studied. Physical restraint
perceptions could be influenced by
the relations between the subject and
one’s environment, with a constructivist
perspective. Therefore, this experience
is a complex social phenomenon and
is difficult to quantify. In this context,
the objective of this study was to
qualitatively evaluate the perception
of dentists on their use of protective
stabilization for dental care in children.
Method
This study follows the standards for
reporting qualitative research.
Participants
Twelve dentists were interviewed,
all with expertise in pediatric dentistry
(degree in pediatric dentistry, either
validated or in progress; hospital
practitioner in pediatric dentistry or
orthodontic department of the University
Hospital of Toulouse). The call for
Month 2020
participation was launched on social
networks among pediatric dentists in
the Toulouse region. The participants
worked in a private dental office, in the
University Hospital of Toulouse, or both.
Seven women and 5 men responded to
the questionnaire. The age ranged from
26 to 50 y. The years in practice ranged
from 2 to 25 y. The researchers were a
final-year dental student and 2 associate
professors with an exclusive pediatric
clinical practice and experience in
qualitative research.
Data Generation
Data were collected between
September and October 2018. Twelve
interviews were necessary to reach
thematic saturation. Ten interviews were
conducted face-to-face in a separate
room of the dentistry department of the
University Hospital of Toulouse. Two
were phone interviews. The interviews
took place during working hours and
were tape recorded. The conversations
were conducted in French. The study
was performed via the qualitative
content (thematic) analysis method
(George et al. 2012). Based on a
review of the literature and discussions
among the 3 investigators, an interview
guide with a short list of questions
was created to help the discussions.
This guide was modified on the basis
of the first interviews according to
hypotheticodeductive methodology.
Questions used in this guide involved
the following thematic areas: definition
of protective stabilization, the situations
in which it was used, the influence of
parents on the decision, the role of
therapeutic alternatives, and the feelings
practitioners had when using protective
stabilization.
Ethical Considerations
The interviews were carried out
within an ethical framework based on
several key points: the guarantee of
anonymity for the interviewees, the
willing acceptance of each interviewee,
and the possibility for each interviewee
to consult the data. This study was
 Vol. XX • Issue X
approved by the division head of the
dentistry department of the University
Hospital of Toulouse, France, and by the
Institutional Review Board of the Faculty
of Dental Surgery of Toulouse, France
(TOU-2019-09-19T08). It followed the
principles of the Declaration of Helsinki
and complied with international ethical
standards.
Analysis
A thematic analysis of the verbatim
records from the individual interviews
was conducted via an inductive
deliberative-type approach. The main
objective of inductive analysis is to
develop categories from the raw data
to integrate them into a reference
framework or model (Denzin and
Lincoln 2005).
The thematic analysis was carried out
as follows. First, the 3 coinvestigators
had a debriefing of the interviews and
drafted an interview report (written
comments by A.M. immediately after
the interview to summarize it, identify
new hypotheses, and prepare for the
next interview). Then, the interviews
were transcribed and the data coded.
Data aggregation was affiliated to the
same code by 1 investigator (A.M.).
NVivo software (version 11; International
QDR) was used for coding. Following
the analysis, we grouped the codes into
general themes. Two investigators (A.M.
and M.C.V.) organized themes using
modifications, mergers, and/or deletions.
Finally, we illustrated with excerpts
of data. A third investigator (M.M.)
submitted the results of the analysis
to the participants and collected their
observations to ensure validity.
Results
The analysis of the interview transcripts
highlights 3 main themes (Table):
•• Perceptions of the dentists concerning
protective stabilization
•• Indications for using protective stabili-
zation in pediatric dentistry
•• Management of the impact of restraint
by dentists
Perception of Protective Stabilization by Pediatric Dentists
Theme 1: Perceptions of the Dentists
Concerning Protective Stabilization
Psychological Impact
The implementation of physical
restraint may have a deep impact
on pediatric dentists. Some of the
participants described a feeling of
discomfort following the use of
protective stabilization: “I was very
uncomfortable after” (interview 4) and
“When I perform protective stabilization,
I feel an intense feeling of unease.
Practically not being in my place”
(interview 7). A feeling of moral and/or
mental exhaustion was also reported: “It
is very stressful for me and my medical
team. Emotionally, it disturbs me a lot.
It’s tiring both nerve-wise and mentally.
It causes great fatigue” (interview 11).
However, some dentists also expressed
the absence of regret: “At the end of
the session, I told myself that I did not
regret it because it was the best solution”
(interview 12).
Feeling of Professional Failure
The use of physical restraint occurs
when behavior management has failed.
Many practitioners expressed this feeling
of professional failure. “I basically think
that when I use some kind of restraint,
I have failed somewhere. For me, it’s a
real failure; it means that everything else
has not worked” (interview 1).
Influence of Personal Life on the Decision
of Protective Stabilization
Separating professional and personal
lives was difficult for some practitioners
when experiencing certain emotions.
Indeed, their personal lives influenced
their relationship with protective
stabilization. For example, some dentists
had personally experienced situations
that they described as violent, and
they made the connection with their
opposition to restraint. “A teacher
smacked me with a ruler, it was a
mistake and it really affected me.
This may be one of the reasons why
I refuse to use any form of restraint”
(interview 4). Another important point
taken into account in the decision
was the dentist’s familial context. For
instance, having or not having children
could change the behavior of the
dentists, including developing a sense
of empathy for children. “I do not have
children, so I know I will be less affected
by certain behaviors than caregivers
who have a child” (interview 6). On the
contrary, one dentist said, “When we
have children, we are really different,
but it’s not in relation to protective
stabilization. This is the only point for
which I do not need the experience
of my children to do my job properly”
(interview 11).
Opposition to the Use of Protective
­Stabilization
Some dentists were totally against
restraint for moral reasons and did
not wish to use it in any way. “I hate
protective stabilization and I will never
use it in my life. My assistant will not
be trained to use restraint because it
is a disaster” (interview 6). However,
the majority of interviewees were more
moderate; they could use restraint in
specific situations, but a questioning of
the consequences of dental treatments
associated with protective stabilization
was sometimes found: “But after the
acts, we think back. Even if it was really
justified, it is not an obvious thing. Was it
justified?” (interview 3).
Theme 2: Indications for
Using Protective Stabilization
in Pediatric Dentistry
Indications Related to the Type and
­Number of Dental Treatments
Dentists implemented protective
stabilization for treatments considered
an emergency. Dental emergencies
included an infection that might develop
into cellulitis, a toothache, or a dental
trauma. In these contexts, protective
stabilization was used to carry out a
treatment that would allow the pain to
decrease or stop: “If the patient has an
abscess on an incisor and the treatment
will last two seconds once the patient
has been anesthetized and there is a risk
that it progresses to cellulitis, then it is
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 JDR Clinical & Translational Research Month 2020

Table.
Three Main Themes and Transcript Highlights.

Main Theme
Subthemes Quotes
The perceptions of the dentists concerning protective stabilization

Psychological impact “Does this [protective stabilization] have an impact on personal life? Yes, clearly. We are not
machines. These are not trivial acts that leave no trace” (interview 3).

Feeling of professional failure “I basically think that when I use some kind of restraint, I have failed somewhere. For me, it’s a real
failure; it means that everything else has not worked” (interview 1).

Influence of personal situation “I do not think I will change the way I act, but I will feel more empathic [if I had children]” (interview 12).

Opposition to the use of protective stabilization “I hate it and I think it’s awful” (interview 1).

Indications for using protective stabilization in pediatric dentistry

Indications related to the type and number of “If we just have a tooth to remove or a single treatment to perform, we will not schedule general
dental treatment anesthesia for that” (interview 3).
“When I see that the diagnosis is not possible without restraint, I start protective stabilization”
(interview 10).

Indications related to child “Mainly for very young children, under 2 years old, because doing a general anesthetic at less than
2 years old to treat cavities bothers me” (interview 11).

Indications related to the environment “When there’s only a dental avulsion to be done, I’m not ask him to drive 4 hours to get to the
hospital” (interview 1).

Protective stabilization to protect the child and “The dental assistant will hold hands to prevent the child from having sudden movements that will
the medical team make me dangerous for the child “ (interview 10).
“Protect the child but us too, if the child catches the anesthesia syringe” (interview 1).

Management of the impact of restraint by dentists

Dehumanization/depersonification “Because in the end, when we use a restraint, we depersonify. The child becomes just a thing to
treat; it’s no longer a child” (interview 5).

Questioning their legitimacy “We must campaign so that [physical restraint] is not condemned, it is important and part of the
therapeutic arsenal” (interview 7).

an emergency that requires protective
stabilization” (interview 1).
Other information taken into account
before making the decision to use
protective stabilization was the global
oral context. Protective stabilization
was used to finish a treatment or
perform a diagnosis (e.g., before general
anesthesia) and “not for a simple
check-up” (interview 3). “We will not
leave the tooth that has a syndesmotomy,
so in this instance we will finish the
treatment with protective stabilization”
(interview 9). For example, if only
1 tooth was affected and associated
with the uncooperative behavior of a
child, protective stabilization could be
performed to avoid general anesthesia.
However, “if there are several treatments
to be done, I consider general
anesthesia” (interview 12). In addition,
protective stabilization was preferably
performed for short procedures or at the
end of a treatment. “If I know I need 3
seconds to finish a procedure, I will. But
if I have to use protective stabilization
for 45 minutes, I will not because it will
degenerate into a nervous breakdown,
and there will be an impact on the child
afterwards” (interview 12).
Indications Related to the Child
First, according to the recommendations
of the AAPD (2017), we highlight that
dentists made the choice to use protective
stabilization when the behavioral
approach failed. “The tooth has a recurring
infection, and antibiotic treatments do not
work. The procedure starts under nitrous
oxide/oxygen inhalation, and the child still
refuses to cooperate—what is the solution?
Wait for general anesthesia or antibiotic
treatments for eternity? I will try protective
stabilization” (interview 2).
The age of the patient was an
important condition for implementing
restraint. Indeed, when a procedure
had to be performed in a child <3 y
old, protective stabilization seemed to
be an acceptable therapeutic solution.
“In the youngest, at 1–2 years old, there

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 Vol. XX • Issue X
is often dental trauma on incisors and
we have to extract them, and there is
no other option outside of protective
stabilization” (interview 3). Another factor
related to the child was the presence
of a disability. Indeed, this was one
of the most common reasons cited by
participants for using physical restraint.
“I often use protective stabilization on
disabled patients. It’s almost systematic”
(interview 6). “In autistic children, the fact
of containing them completely physically
has rather a reassuring, positive effect
on them compared with other children”
(interview 9). Finally, it emerged from the
interviews that the analysis of the child’s
behavior was crucial to better understand
if the child was temperamental or
afraid. With a scared child, protective
stabilization should be ruled out to avoid
aggravating this fear. “I use protective
stabilization in really targeted cases,
when I feel that the child just does
not want to be there and is just being
temperamental and nothing else than that
[anxiety, fear of pain]” (interview 11).
Indications Related to the Environment
The implementation of physical
restraint was also linked to the care
environment. Of course, protective
stabilization in children requires
informed consent from a parent. This
notion was found in all interviews.
However, the influence of parental
behavior on the dentist’s decision to
use protective stabilization seemed to
be dependent on the medical team.
Sometimes there was no influence: “I will
not decide to use protective stabilization
even if parents ask me. I have my ideas
and the parents do not influence me”
(interview 9). Sometimes the practitioner
was influenced or under pressure from
an insistent family, and this can add to
the difficulty of performing dental care
under protective stabilization: “There are
treatments that we will try, even using
protective stabilization, when the parent
is strongly seeking attempted care”
(interview 1). In addition, the social,
economic, or geographic contexts in
which the child had grown influenced
the decision of protective stabilization by
Perception of Protective Stabilization by Pediatric Dentists
the dentist. “I did that because the family
context was unusual, with a rather low
social level” (interview 2).
Protective Stabilization to Protect the Child
and the Medical Team
Dental treatment requires using several
instruments that could injure the patient
in the event of uncontrolled movements.
This starts from the beginning of the
treatment, with the administration of
anesthesia, and continues with the use of
rotary dental instruments. “They can hurt
themselves with our own instruments.
We can hurt them very badly. A rotary
dental instrument in the mouth of a child
who moves a lot can quickly become
problematic” (interview 11).
The child’s movements during the
treatment can hurt not only the child
but also the medical care team. In these
cases, protective stabilization was used to
“protect the child but us too, if the child
grabs the anesthesia syringe” (interview 1).
Theme 3: Management of the
Impact of Restraint by Dentists
“Depersonification”
Dehumanization, or “depersonification,”
is the treatment of another person
as something other than the unique
individual that he or she really is. At the
time of using protective stabilization,
the dentist can protect himself or herself
psychologically by depersonalizing the
child, who then becomes only an object
of care. “Because in the end, when we
use a restraint, we ‘depersonify.’ The
child becomes just a thing to treat; it’s no
longer a child” (interview 5).
Discussion With the Dental Assistant
To understand and analyze the impact
of this kind of procedure, the dentists
discussed it with the dental assistants
to exchange points of view and share
feelings after the treatment. “We discuss:
‘How do you experience it? Would you
have done the same thing?’ Because
we talk a lot and we do not have an
employee-employer relationship but
more a relationship where they are my
‘right arm’” (interview 12).
Reflection on Parenting
The environment plays a great role
in child behavior. This is why the use
of protective stabilization led dentists
to question the role of parental
education in the behavior of the child.
“If the child has had too flexible of an
upbringing, as a caregiver, the situation
becomes too difficult” (interview 10).
Some parents do not want to force their
children to do things that they do not
want to do, even with regard to their
hygiene or health: “It’s coming to that
point: ‘You do not want to brush your
teeth, so be it.’ I find it very serious.
So this makes us have to use means
of restraint that are much stronger,
carried out by a stranger, namely me.
It’s worse. They put them in difficult
situations without realizing it. Under
the pretext of not imposing anything
on the child, they are imposing terrible
things on them. . . . In these cases, I
ask the parents to take a little more
responsibility” (interview 10).
Questioning the Legitimacy of Their Use
of Protective Stabilization
The legitimacy of achieving protective
stabilization was a subject for reflection of
several dentists. “It’s harder for me to do
it, and I do not feel there is a legitimate
reason to do it” (interview 12). This lack
of legitimacy could be explained by the
fact that in France there is legal uncertainty
about the use of restraint: “In the society in
which we live, people quickly complain.
We are quickly accused of mistreatment”
(interview 2). “From a legal point of view,
we must be able to support why we used
restraint” (interview 9). However, training
would improve the use of restraints.
“I do not know how to practice it. . . .
Practitioners must be trained in this and it
is very complicated” (interview 7).
Discussion
To our knowledge, this study is the first
to investigate the use and consequences
of physical restraint in pediatric dentistry
via qualitative methodology. Based on
a thematic analysis, this work offers a
description of the reasons why protective
5
 JDR Clinical & Translational Research
stabilization is used or not and what
effects it has on practitioners.
Contention: A Feeling of Unease
Dentists used protective stabilization
as a last resort, when behavior guidance
techniques had failed. During the
interviews, the dentists described
negative feelings when using protective
stabilization. Feeling “uncomfortable”
and “unpleasant” were notions found
throughout the interviews and were
often associated with a feeling of failure.
These feelings were concordant
with the qualitative study of Lombart
et al. (2019) conducted with nurses in
a pediatric unit in France. They were
asked about their feelings when they use
physical restraints on children. Despite
the fact of being “blinded” by the care,
several feelings were highlighted, such
as sadness, guilt, and compassion/pity
toward the patients. A qualitative study
by Sequeira and Halstead (2004) occurred
in a psychiatric ward in England. Nurses
were interviewed, and feelings of anxiety,
anger, and frustration were mentioned.
They were afraid of hurting themselves
or a patient. Boredom, demoralization
(low morale), and emotional distress
(crying) were also described but found
exclusively in female staff.
In our study, the private lives of several
dentists, such as being a parent, seemed
to play a role in their practice. In this case,
they described a greater sense of empathy.
In the studies by Chuang and Huang
(2007) and Fradkin et al. (1999; analyzing
interviews with student nurses about the
use of physical restraint in a geriatric ward
in Israel), the concept that personal life
influenced professional life was found and
accentuated this feeling of guilt.
In addition, the idea that a change in
parenting has an impact on a child’s
behavior was raised in the interviews.
Casamassimo et al. (2002) described
dentists’ negative perceptions of
changes in parenting styles toward a
more permissive, less authoritarian style
and the belief that this had adversely
influenced behavior and caused
changes in pediatric dentists’ behavior
management.
6
Necessity or Moral Obligation
of Performing Dental Care
Despite these negative perceptions,
dentists used protective stabilization with
children. The majority of interviewees
stated that it is a part of their therapeutic
arsenal. However, internal conflict arose
among the necessity to use restraint,
the dentists’ professional responsibility,
and their convictions associated with
respecting the patient’s dignity. This
dilemma has been found in other
studies (Sequeira and Halstead 2004;
Chuang and Huang 2007), and this
antagonism has been described among
nurses and physicians (Svendsen et al.
2017). Professional ethics define what
an individual believes to be morally
correct in his or her profession, while
professional deontology is a code of
conduct that applies to all professionals.
The question of restraint therefore is
based on ethics. The practitioner has
to make the distinction between the
ethics of responsibility and the ethics of
conviction (Frangne and Morel 2015).
The ethics of responsibility in care allows
compromise, contrary to the ethics of
conviction, for which no accommodation
is possible. The practitioner must
overcome some of his or her convictions
to provide care.
How to Manage the Psychological
Impact of Restraint
In our study, the use of protective
stabilization in children had psychological
implications for caregivers. Strategies to
better manage the negative impacts have
been described, such as rationalization
(being convinced that restraint is used
for good reasons), compensation (spend
disproportionate time with the person
after having contained it), as well as
sharing experiences with colleagues
(Chuang and Huang 2007). Nevertheless,
these techniques have limitations. In
our study, some dentists described their
discussion about restraint with the dental
assistant, but none reported discussions
among other practitioners. One dentist
used the notion of “depersonification.” By
dehumanizing the patient, the practitioner
disconnected his or her feelings toward
Month 2020
the patient for the purpose of the
treatment. In another study, caregivers
reported limiting their feelings to
preserve themselves psychologically
(Sequeira and Halstead 2004).
A Desire for Training
Dentists have expressed the need
for training in protective stabilization.
They ask for specific recommendations
on when and how to provide physical
restraint. They also want to have the
opportunity to share their experiences
within the medical team about the
consequences of using protective
stabilization. This idea was found
in the literature, associated with the
need to organize meetings in which
everyone can express experiences and
emotions and suggest ideas to ensure
less restrictive care (Bonner et al. 2002;
Sequeira and Halstead 2004; Chuang and
Huang 2007). In France, these meetings
are uncommon, but in recent years
we have managed to have numerous
meetings on this subject with dentistry
students.
Peretz and Gluck (2002) studied the
cultural factors that influenced dentists’
use of protective stabilization and
concluded that the place of practice, the
prevalence of caries, and the education
received by the dentist played a role in
the choice of behavioral strategy used.
These techniques varied according to the
age of the dentist and the dental faculty
in which he or she studied.
There is no consensus on the use
of physical restraint in medicine. The
practitioner decides according to one’s
convictions and available alternative
care options. Therefore, we can state
that practitioners need to be supported
in their decision making, presumably
with 1) better teaching of behavioral
management of children in schools of
dental surgery, notably through narrative
medicine, and/or 2) new guidelines
to provide a better-defined framework
to the use of protective stabilization
(Sequeira and Halstead 2004). This
would make it possible to reduce the
mental burden that adds to the technical
difficulty of the care.
 Vol. XX • Issue X
Limitations of the Study
The limitations of this qualitative
analysis are the typical ones for this
type of research. They are primarily
related to the researcher’s subjectivity
in conducting the interviews and in
analyzing and interpreting the results.
However, this is positive subjectivity,
as it is the researcher’s sensitivity that
led to the subject under study. In this
case, the methodology described herein
allowed the impact of subjectivity to
be minimized. Indeed, each step was
carried out by at least 2 researchers, and
the results were submitted for external
validation. Finally, the constitution
of the researcher triad, made up of
practitioners with different sensitivities,
enabled a factual interpretation of the
results.
Conclusion
Dentists often have to treat children
who refuse an examination or dental
treatment. When agitated, patients can
injure themselves or a member of the
medical team. Some of these children
are then held through force by an adult
or by a mechanical device. Although
physical restraint appears to be widely
used in the field of dental surgery,
no studies have been conducted to
investigate practitioners’ perceptions.
The choice of a qualitative analysis
methodology allowed us to define
situations in which restraint is used but
also to highlight the negative effects that
this practice can have on practitioners.
Of course, participants stressed that
the interest of the child governs the
decision to use protective stabilization.
This technique should be used only after
considering alternate strategies for caring
for the child.
The dental surgeon must combine
respect for the rights of the child and the
imperative to make concrete decisions
regarding the provision of care. This
study shows the need for specific
training on this subject as well as the
desire of certain dentists that public
authorities implement legislation on this
matter.
Perception of Protective Stabilization by Pediatric Dentists
Author Contributions
M. Marty, contributed to conception,
design, data acquisition, analysis, and
interpretation, drafted the manuscript; A.
Marquet, contributed to data acquisition,
analysis, and interpretation, drafted the
manuscript; M.C. Valéra, contributed to
conception, design, data acquisition,
analysis, and interpretation, drafted
the manuscript. All authors gave final
approval and agree to be accountable for
all aspects of the work.
Declaration of Conflicting Interests
The authors declared no potential
conflicts of interest with respect to the
research, authorship, and/or publication
of this article.
Funding
The authors received no financial
support for the research, authorship,
and/or publication of this article.
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