Dental Care for Children with Special Needs, p.
247
PROTECTIVE STABILIZATION IN THE DENTAL SETTING
PROTECTIVE STABILIZATION
- the restriction of a patient's freedom of movement,
with or without the patient's permission, to decrease
risk of injury while allowing safe completion of
treatment
- Other terms for Protective Stabilization:
- Restrictive behavior guidance technique
- Medical Immobilization
OBJECTIVES FOR APPLYING PROTECTIVE STABILIZATION
1. Reduce or eliminate sudden, uncontrolled, or
aggressive movement of the child's head, jaw, body or
limbs
2. Provide stability for the child in the dental chair
3. Protect the child and oral health staff from injury
4. Facilitate delivery of quality oral health procedure
5. Protective stabilization should be reserved for only the
most serious problem behavior, and it should only be
used after less restrictive procedures are shown to be
ineffective and in conjunction with other proactive
therapies
“You have to remember that our convenience should
never be part of our objectives.”
INDICATIONS
1. The child requires immediate diagnosis and/or urgent
limited treatment and cannot cooperate due to
emotional maturity or medical and physical conditions.
2. Emergency care is needed and uncontrolled
movements risk the safety of the child, staff, dentist,
or parent without the use of protective stabilization;
3. A previously cooperative child quickly becomes
uncooperative during the appointment in order to
protect his/her safety and help to expedite completion
of treatment.
○ But if the treatment is not urgent, then you
can actually defer the treatment.
4. A child is sedated and becomes uncooperative during
treatment
5. A child with special health care needs who may
experience uncontrolled movements that would be
harmful or significantly interfere with the quality of
care
● Protective stabilization should only be used when
necessary to protect the individual and others during
a dental appointment and should not be used for
coercion, convenience, or punishment
CONTRAINDICATIONS
● A cooperative non-sedated patient.
- We usually use Protective Stabilization when
the child is sedated, we seldom use it if the
child is non-sedated.
● An uncooperative patient when there is not a clear
need to provide treatment at that particular visit
● A patient who cannot be immobilized safely due to
associated medical, psychological or physical
conditions
● A patient with a history of physical or psychological
trauma
● Non-emergent treatment needs
● A practitioner's convenience
● Dental team without proper training
CONSIDERATIONS REGARDING USE OF PROTECTIVE STABILIZATION
1. Alternative behavior guidance techniques that could
be used instead.
- We don't use Protective Stabilization when
other guidance techniques can still be used
2. The child's oral health needs.
- Is there an urgent need or not?
- Is it extensive?
3. The length and invasiveness of the procedure
4. The effect of this technique on the quality of oral
health care
5. The child's emotional and cognitive developmental
levels
6. The child's medical and physical condition
7. The oral health professional's comfort with, and skill
in, using these techniques
8. Parents understanding and acceptance of their use
PRECAUTIONS
● Review medical history and past history of the patient
● Constant monitoring
● Stabilization around extremities or the chest must not
actively restrict circulation or respiration
● Observation of body language and pain assessment
stabilization should be terminated as soon as possible
in a patient who is experiencing severe stress or
hysterics to prevent possible physical or psychological
trauma.
ENVIRONMENT
● Protective stabilization should be used in an
environment of family and caregiver involvement, and
most parents feel they should be present to increase
the child’s stability and comfort.
● While parental presence and involvement should be
encouraged, parents should not be made to feel guilty
if they do not want to be present.
○ If they choose to be absent, it should be
documented.
● If parents are denied access, they must be informed
of the reason, and the rationale must be documented
in the patient’s chart.
DOCUMENTATION
1. Type of stabilization used
2. Indication for stabilization
INFORMED CONSENT
1. Signed by the parents/guardian
- The process of informed consent is an
ethical obligation and a legal requirement
that goes beyond a signature on a consent
form
- In the case of protective stabilization, it is
advisable to obtain specific, written informed
consent
2. Duration of stabilization
3. Reason for parent exclusion during stabilization (if
applicable)
- Example: If the parent is highly anxious you
request the patient to be excluded in the
stabilization
4. Behavior evaluation/ rating during stabilization
- Frankl behavior
- Rate how much movement
- If there is an interruption in the treatment
even with the stabilization

5. Any untoward outcome, such as skin markings, and
management implications for future appointments
- Even if it’s very mild, you have to note (Ex. A
light scratch; you still have to note it and
where)
● It is also prudent to document the reason for a
specific stabilization type.
● Typically, adverse outcomes related to medical
immobilization are minor scratches or bruising.
● Regardless of the severity, adverse outcomes should
be documented.
● If protective stabilization is implemented but was
unplanned, the reason for its use and method of
obtaining consent should be documented along with
plans for future treatment.
● The overall effectiveness of stabilization should be
documented after the appointment
TYPES OF RESTRAINTS
- In Dentistry we usually just use Physical and
Chemical restraint.
1. PHYSICAL
- It is when we use something mechanical, or when
somebody will use their body to restrain someone
2. CHEMICAL
- A drug that is used to make somebody drowsy,
becomes sedated for us to be able to use such
treatment.
- But usually it is in combination with Physical and
Chemical
- Chemical restraints are any drug used for discipline or
convenience and not required to treat medical
symptoms.
3. GENERAL BEHAVIORAL
- General Behavioral restraint is usually your timeout
rooms, which is not usually used in dentistry.
KNEE TO KNEE EXAM
- Is a kind of restrictive behavior guidance technique
- Give support to the child patient and at the same time
they will be able to see the parent most of the time
- This exam is primarily used for very young children
unable to cooperate for examination in the dental
Dental Care for Children with Special Needs, p. 247
chair, but it may be used for older CSHCN when
patient size permits safe positioning
● During these examinations it is important to protect
the child from injuring himself by closing on dental
instruments such as the mirror or explorer.
● For very young children with few teeth, the dentist can
place a finger on the alveolar ridge posterior to the
most erupted tooth to prevent the child from closing.
● Older children with more teeth erupted may benefit
from the use of a foam or child-sized mouth prop if
both the mirror and explorer are needed.
● Knee-to-knee positioning is almost universally
acceptable to parents, and even critics that oppose
any type of restraint generally agree that some type of
physical contact and steadying is acceptable in
pediatric dentistry
ACTIVE STABILIZATION (Physical or personal restraint)
- Restraint by another person
- Not by a mechanical restraint (somebody is holding
the hand, legs, or doing a headlock etc.)
● Active stabilization or “holding” must avoid the use of
unnecessary force, which could cause pain or put
pressure on joints
● Sometimes parts of the patient’s body are gently held,
and pressure is intended only as resistance to slow
down the speed and force of movement
PASSIVE IMMOBILIZATION / STABILIZATION
● Passive immobilization involves the use of
mechanical devices which assist the patient in
remaining properly positioned
○ Examples include Papoose Boards,
Pedi-Wraps, sheets, straps, seat belts,
towels, wrist bracelets, and vests
● Typically the use of passive immobilization is
accompanied by active immobilization to apply the
mechanical device or to immobilize portions of the
body that are not restrained by the device, so consent
for both methods is prudent
POSITIONING DEVICES OR STABILIZERS
● Wheelchair head supports may already be present on
the chairs of patients with muscular instability
disorders.
 Dental Care for Children with Special Needs, p. 247

○ These can be used to provide familiarity and

support during dental procedures
● The use of chairlifts can securely place the chair in an
ergonomically acceptable position for the dental
provider during lengthier procedures.
● For patients who are transferred to the dental chair,
additional means of support should be used to ensure
patient comfort and stability
○ Bean bag pillows or chairs may be placed
into the reclined dental chair to stabilize the
patient’s body

PASSIVE STABILIZATION / MOUTH PROP

- Use of mechanical device (bite block, mouth gag)
- To restrain somebody from closing their mouth. But
first explain to your patient in a way that is
non-threatening

Read case-based scenario in the book.

CONCLUSION
● Protective stabilization can be a useful adjunct to
other behavior guidance techniques or a last resort
when they fail.
● Due to the history of the improper use of restraint in
individuals with CSHCN, dentists should understand
the rationale behind protective stabilization in
dentistry and indications for its use.
● Proper informed consent and documentation are
essential when implementing protective stabilization.