Home > Research > Oral Health Policies & Recommendations

Protective Stabilization for Pediatric Dental Patients

Purpose

The American Academy of Pediatric Dentistry (AAPD) believes that all infants, children, adolescents, and individuals with special health care needs are entitled to receive oral health care that meets the treatment and ethical principles of our specialty. The AAPD has included use of protective stabilization (formerly referred to as physical restraint and medical immobilization) in its guidelines on behavior guidance since 1990.1-9  This separate document, specific to protective stabilization, provides additional information to assist the dental professional and other stakeholders in understanding the indications for and developing appropriate practices in the use of protective stabilization as an advanced behavior guidance technique in contemporary pediatric dentistry. This advanced technique must be integrated into an overall behavior guidance approach that is individualized for each patient in the context of promoting a positive dental attitude for the patient, while ensuring the highest standards of safety and quality of care. 

Methods

Recommendations on protective stabilization were developed by the Council on Clinical Affairs and adopted in 2013. This document is a revision of the previous version and is based on a review of the current dental and medical literature related to the use of protective stabilization devices and restraint in the treatment of infants, children, adolescents, and patients with special health care needs in the dental office. This revision included electronic database searches using the terms: protective stabilization and dentistry, protective stabilization and medical procedures, medical immobilization, restraint and dentistry, restraint and medical procedures, Papoose® board and dentistry, Papoose® board and medical procedures, and patient restraint for treatment. Fifty articles matched these criteria and were evaluated by title and/or abstract. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians.

Definitions

Physical restraint is broadly defined by the Centers for Medicare and Medicaid Services as “(A) 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; or (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restart the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.”10  This definition has limitations when applied to dentistry as it does not accurately or comprehensively reflect the indications or utilization of restraint in dentistry.

Protective stabilization is the term utilized in dentistry for the physical limitation of a patient’s movement by a person or restrictive equipment, materials or devices for a finite period of time10-14 in order to safely provide examination, diagnosis, and/or treatment.

Other terms such as medical immobilization and medical immobilization/protective stabilization have been used as descriptors for procedures categorized as protective stabilization.13-15  Active immobilization involves restraint by another person, such as the parent, dentist, or dental auxiliary. Passive immobilization utilizes a restraining device.15

Background

Pediatric dentists receive formal education and training to gain the knowledge and skills required to manage the various physical challenges, cognitive capacities, and age-defining traits of their patients. A dentist who treats children should be able to assess each child’s developmental level, dental attitude, and temperament and also be able to recognize potential barriers to delivery of care (e.g., previous unpleasant and/or painful medical or dental experiences) to help predict the child’s reaction to treatment.9  A continuum of non-pharmacological and pharmacological behavior guidance techniques, including protective stabilization, may be employed in providing oral health care for infants, children, adolescents, and individuals with special health care needs.9 Behavior guidance approaches for each patient who is unable to cooperate should be customized to the individual needs of the child and the desires of the parent and may include sedation, general anesthesia, protective stabilization, or referral to another dentist.9  The AAPD Guideline on Behavior Guidance for the Pediaric Dental Patient9 should be consulted for additional information regarding the spectrum of behavior guidance techniques.

When determining whether to recommend use of stabilization or immobilization techniques, the dentist should consider the patient’s oral health needs, emotional and cognitive development levels, medical and physical conditions, and parental preferences.11  Furthermore, alternative approaches (e.g., treatment deferral, sedation, general anesthesia) and their potential impact on quality of care and the patient’s well-being should be included in the deliberation.11

Recommendations

Education.  Didactic and clinical experiences vary for predoctoral students between and within dental schools. While some schools provide didactic and hands-on training in advanced behavior guidance, others offer limited exposure. A survey of pre-doctoral program directors found a majority of dental schools spend fewer than five classroom hours on behavior guidance techniques.15  Furthermore, 42 percent of institutions reported fewer than 25 percent of students had one hands-on experience with passive immobilization for non-sedated patients, while 27 percent of programs provided no clinical experiences.15  A predoctoral dental survey demonstrated 73 percent of students were instructed on use of an immobilization device (Papoose® board); however, only 11 percent observed use in clinical settings, with two percent actually using it on a patient.16,17  Therefore, graduates from dental school may lack knowledge and competency in the use of protective stabilization. Limited training in protective stabilization is not unique to dentistry as other health care disciplines have suggested a need for advanced training and guidelines.18,19

Protective stabilization is considered an advanced behavior guidance technique in dentistry.9  Attempts to restrain or stabilize patients without adequate training can leave not only the patient, but also the practitioner and staff, at risk for physical harm.20  Both didactic and hands-on mentored education beyond dental school is essential to ensure appropriate, safe, and effective implementation of protective stabilization of a patient unable to cooperate.9  Advanced training can be attained through an accredited post-doctoral program (e.g., advanced education in general dentistry, general practice residency, pediatric dentistry residency) or an extensive and focused continuing education course that includes both didactic and mentored hands-on experiences. Formal training will allow the practitioner to acquire the necessary knowledge and skills in patient selection and in the successful use of restraining techniques to prevent or minimize psychological stress and/or decrease risk of physical injury to the patient, the parent, and the staff. Currently, at least one state (Colorado) requires training beyond basic dental education in order for the practitioner to utilize protective stabilization devices.21

Consent.  Protective stabilization, with or without a restrictive device, led by the dentist and performed by the dental team requires informed consent from a parent*.9 A parent’s signature on a consent form should not preclude a thorough discussion of the procedure. The practitioner must explain the benefits and risks of protective stabilization, as well as alternative behavior guidance techniques (e.g., treatment deferral, sedation, general anesthesia), and assist the parent in determining the most appropriate approach to treat his/her child.22 Informed consent discussion, when possible, should occur on a day separate from the treatment. Supplements such as informational booklets or videos may be helpful to the parent and/or patient in understanding the proposed procedure. Informed consent must be obtained and documented in the patient’s record prior to performing protective stabilization.12,21,23,24 If a patient’s behavior during treatment necessitates a change in stabilization procedure or technique, further consent must be obtained and documented.23

When appropriate, an explanation to the patient regarding the need for restraint, with an opportunity for the patient to respond, should occur.11,21 Although a minor does not have the statutory right to give or refuse consent for treatment, the child’s wishes and feelings (assent) should be considered when addressing the issue of consent.23 Also, when providing dental care for adolescents or adults with mild intellectual disabilities, patient assent for protective stabilization should be considered.13 A conditional comprehensive explanation of the technique to be used and the reasons for application should be provided.13

Laws governing informed consent vary by state. It is incumbent on the practitioner to be familiar with applicable statutes. Currently, most states have adopted the patientoriented standard. Thus, a practitioner may be held liable if a parent has not received all of the information that is essential to his/her decision to accept or reject proposed treatment.23

Written consent before treatment of a patient is mandated by some states.25 Even if not required by state law, detailed written consent for medical immobilization should be obtained separately from consent for other procedures as it increases the parent’s/patient’s awareness of the procedure.23

__________________________________________________________________________________________________________________
* In all AAPD oral health care policies and clinical recommendations the term “parent” has a broad meaning encompassing a natural/biological father or mother of a child with full parental legal rights, a custodial parent who in the case of divorce has been awarded legal custody of a child, a person appointed by a court to be the legal guardian of a minor child, or a foster parent (a noncustodial parent caring for a child without parental support or protection who was placed by local welfare services or a court order). American Academy of Pediatric Dentistry. Overview. Pediatr Dent 2017;39(6):5-7.

Parental presence.  Parental presence in the operatory may help both the parent and child during a difficult experience.26  Ninety-two percent of mothers in one study believed they should have been with their child when he/she was placed on a rigid stabilization board to increase the child’s security and/ or comfort.26  In addition, 90 percent recognized that immobilization protected the children from harm.26  The dentist should consider allowing parental 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, or the dental staff would be at risk.8  Further, if parents are denied access, they must be informed of the reason with documentation of the explanation in the patient’s chart.21  If parents choose not to be present, they should be encouraged to provide positive nurturing support for the child both before and after the procedure. Ultimately, a parent has the right to terminate use of restraint at any time if he or she believes the child may be experiencing physical or psychological trauma due to immobilization. If termination is requested, the practitioner immediately should complete the necessary steps to bring the procedure to a safe conclusion before ending the appointment.

Techniques.  Alternative approaches to restricting patient movement during medically necessary dental care should be explored before immobilizing a patient. Protective stabilization should be used only when less restrictive interventions are not effective. It should not be used as a means of discipline, convenience, or retaliation. Furthermore, the use of protective stabilization should not induce pain for the patient.

Treatment should first be attempted with communicative behavior guidance without protective stabilization unless there is a history of maladaptive or combative behavior that could be injurious to the patient and/or staff.27  Active immobilization involves limitation of movement by another person, such as the parent, dentist, or dental auxiliary, whereas passive (mechanical) immobilization requires use of restraints. When mechanical immobilization is indicated, the least restrictive alternative or technique should be used.28,29

An accurate, comprehensive, and up-to-date medical history is necessary for effective treatment. This would include careful review of the patient’s medical history to ascertain if there are any conditions (e.g., asthma) which may compromise respiratory function or neuromuscular or bone/skeletal disorders which may require additional positioning aids due to rigid extremities.

Following explanation of the procedures and consent by the parent, protective stabilization of the patient should begin in conjunction with distraction techniques30 by placing the child, in a manner as comfortable as possible, in a supine position. If restriction of extremity movement is needed, the dentist may ask a dental auxiliary or parent to employ hand guarding or hold the patient’s hands. Full-body protective stabilization, when indicated, should be accomplished in a sequential manner.31  If the stabilization device includes a head hold, that is activated last. At no time should the device be active to the point of restricting blood flow or respiration.9

Equipment.  Numerous devices are available to limit movements by a patient unable to cooperate during dental treatment. The ideal characteristics of a mechanical restraining device to use as an adjunct to dental procedures include the following:

  • easily used.
  • appropriately sized for the patient.
  • soft and contoured to minimize potential injury to the patient.
  • specifically designed for patient stabilization (i.e., not improvised equipment).31
  • able to be disinfected.

Stabilization of a patient’s extremities can be accomplished using devices (e.g., Posey straps®, Velcro® straps, seat belts) or an extra assistant. If hand guarding or hand holding does not deter disruptive movement of a patient’s hands, wrist restraints may be utilized.27,32  If a patient is unable (due to medical diagnosis) or unwilling (due to maladaptive behaviors) to control bodily movement, a full body wrap may need to be used. Full-body stabilization devices include, but are not limited to, Papoose Board® and Pedi-Wrap®.27,32  Stabilization for the head may be accomplished using forearm-body support, a head positioner, or an extra assistant.32  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.

Monitoring.  Ongoing awareness/assessment of the patient’s physical and psychological well-being during the dental procedure must be performed. Tightness of the stabilization device must be monitored continuously throughout the procedure.9  For a patient who is experiencing severe emotional stress or hysterics, protective stabilization must be terminated as soon as possible to prevent possible physical or psychological trauma.28  At the completion of dental procedures, removal of restraints should be accomplished sequentially with short pauses between stages to assess the patient’s level of cooperation.27  Struggling during removal of restraints may increase the potential for injury to the child as well as others. When immobilization has been introduced intra-operatively (i.e., unplanned intervention), debriefing is beneficial for the understanding of parent/patient20 and to discuss management implications for future appointments.

Patients with special health care needs.  The provider should consider utilizing alternative behavioral approaches to reduce movement and resistance as well as increase cooperation when providing medically necessary dental care for patients with special health care needs (SHCN) prior to implementing protective stabilization.34  Various behavioral modification approaches such as distraction, shaping, modeling, sensory integration, desensitization, and reinforcement are regarded as alternatives.34-36  D-Termined Program© is a non-pharmacological behavior guidance approach that has been effective in patients with autism spectrum disorders (ASD).14,37-39  This program uses familiarization through repetitive tasking by skill training in acceptable behaviors in the dental operatory.14,37-39  Distraction via counting, positional modeling, and repetitive tasks and visits are modalities implemented to facilitate coping strategies for ASD patients.14,37-39

Children and adolescents with SHCN 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.40  Use of protective stabilization reduces potential risks and provides safer management of patients with SHCN.40,41  Studies have demonstrated that sensory adapted environments and techniques such as deep pressure from an immobilization device (Papoose® board) provided comfort, reduced effects of stressful stimuli, and were observed to be non-harmful to special needs patients receiving medical and dental care.40,41  One study reported parents of children with SHCN had greater acceptance of protective stabilization in comparison to parents of children with no disabilities.42  When considering protective stabilization during dental treatment for patients with SHCN, the dentist in collaboration with the parent must consider the importance of treatment and the safety consideration of the restraint.13  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.43

Indications.  Protective stabilization is indicated when: 

  • 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.
  • urgent care is needed and uncontrolled movements risk the safety of the patient, staff, dentist, or parent without the use of protective stabilization.
  • apreviously cooperative patient quickly becomes uncooperative during the appointment in order to protect the patient’s safety and help to expedite completion of treatment.
  • an uncooperative patient requires limited (e.g., quadrant) 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 preferences after other options have been discussed.
  • asedated patient requires limited stabilization to help reduce untoward movements during treatment.
  • a patient with SHCN exhibits uncontrolled movements that would be harmful or significantly interfere with the quality of care. 

Contraindications:  Protective stabilization is contraindicated for:

  • cooperative non-sedated patients. 
  • patients who cannot be immobilized safely due to associated medical, psychological, or physical conditions.
  • patients with a history of physical or psychological trauma due to immobilization (unless no other alternatives are available).
  • patients with non-emergent treatment needs in order to accomplish full mouth or multiple quadrant dental rehabilitation; and
  • the practitioner’s convenience.

Risks.  The provider should consider the patient’s emotional and cognitive developmental levels and should be aware of potential physical and psychological effects of protective stabilization.9  The majority of restraint-related injuries consist of minor bruises and scratches, although other more serious injuries have been reported.43,44  Fewer injuries were incurred due to passive stabilization compared to active stabilization, and fewer injuries occurred with the use of planned passive stabilization compared to its use in emergent situations.44 Patients placed on a rigid stabilization board may overheat during the dental procedure. They must never be unattended while placed in the board as they may roll out of the chair.28  A rigid stabilization board may not allow for complete extension of the neck and, therefore, may compromise airway patency, especially in young children or sedated patients.45  Proper training and use of a neck roll may minimize this risk. Significant release of adrenal catecholamines may exist in patients who experience increased agitation when restrained by staff members or protective stabilizing equipment.43  Excessive catecholamine release may sensitize the heart and cause rhythm disturbances.43

The dental provider should acknowledge and abide by the principle to “do no harm” when considering completion of excessive amounts of treatment while the patient is immobilized with protective stabilization.46  The physical and psychological health of the patient should override other factors (e.g., practitioner convenience, financial compensation).46

Documentation.  The patient’s record must include:

  • indication for stabilization.
  • type of stabilization. 
  • informed consent for protective stabilization.
  • reason for parental exclusion during protective stabilization (when applicable).
  • the duration of application of stabilization.
  • behavior evaluation/rating during stabilization.
  • any untoward outcomes, such as skin markings.
  • management implications for future appointments.

References

  1. American Academy of Pediatric Dentistry. Guideline for behavior management. Chicago, Ill.; May, 1990. 
  2. American Academy of Pediatric Dentistry. Guideline for behavior management. In Reference Manual 1991-1992.  American Academy of Pediatric Dentistry. Chicago, Ill.;  1991:49-53.
  3. American Academy of Pediatric Dentistry. Guideline for behavior management. Pediatr Dent 1996;18(special issue):40-4.
  4. American Academy of Pediatric Dentistry. Guideline for behavior management. Pediatr Dent 2000;22(special issue):47-51. 
  5. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the Pediatric Dental Patient.  Pediatr Dent 2005;27(suppl issue):92-100.
  6. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the Pediatric Dental Patient.  Pediatr Dent 2006;28(suppl issue):97-105.
  7. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the Pediatric Dental Patient.  Pediat Dent 2008;30(suppl issue):125-33.
  8. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the Pediatric Dental Patient.  Pediatr Dent 2011;33(special issue):161-73.
  9. American Academy of Pediatric Dentistry. Guideline on behavior guidance for the Pediatric Dental Patient.  Pediatr Dent 2015;37(special issue):180-93. 
  10. Office of the Federal Register. Code of Federal Regulations. Title 42 Public Health, 482.13; 2011. Available at: “https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5.pdf”. Accessed January 28, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6tbQPCBML”)
  11. Royal College of Nursing. Restrictive physical intervention and therapeutic holding for children and young people. Guidance for nursing staff. 2010. London: RCN. Available at: “http://www.rcn.org.uk/__data/assets/pdf_file/0016/312613/003573.pdf ”. Accessed January 28, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6sk3mBI97”)
  12. NYS Office for People with Developmental Disabilities. Administrative Memorandum-#2010-02. Medical immobilization/protective stabilization (MIPS) and sedation for medical/dental appointments. 2010;1-7. Available at: “http://www.opwdd.ny.gov/node/961”. Accessed January 28, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6sk43QNt9”)
  13. Newton JT. Restrictive behaviour management procedures with people with intellectual disabilities who require dental treatment. J Appl Res Intellect Disabil 2009;22(2):118-25.
  14. Tesini DA. Providing comprehensive quality dental care to children with autism spectrum disorder. Inside Dental Assisting 2014;March/April:22-7. Available at: “http://editiondigital.net/publication/?i=201523&p=24#{“page”:24,”issue_id”:201523}”. Accessed July 2, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6sk4PXHzn”)
  15. Adair SM, Schafer TE, Rockman RA, Waller JL. Survey of behavior management teaching in predoctoral pediatric dentistry programs. Pediatr Dent 2004;26(2):143-50.
  16. York KM, Mlinac ME, Deibler MW, Creed TA, Ganem I. Pediatric behavior management techniques: A survey of predoctoral dental students. J Dent Educ 2007;71(4): 532-9.
  17. Quiñonez RB, Nelson T. Pediatric Behavior Guidance for the 21st Century Workshop C Report–Advocacy and Policy. Pediatr Dent 2014;36(2):158-60. 
  18. Valler-Jones T, Shinnick A. Holding children for invasive procedures: Preparing student nurses. Paediatr Nurs 2005;17(5):20-2.
  19. Graham P, Hardy M. The immobilization and restraint of paediatric patients during plain film radiographic examinations. Radiography 2004;10(1):23-31.
  20. Lambreno K, McArthur E. Introducing a clinical holding policy. Paediatr Nurs 2003;15(4):30-3.
  21. State of Colorado Department of Regulatory Agencies. Board of Dental Examiners. 3CCR709-1. Rules and Regulations; Medical immobilization/protective stabilization. 2011; 37-8. Available at: “http://www.nasddds. org/uploads/documents/
    CO_Dental_Restraints_Policy. pdf”. Accessed January 28, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6sk4aqfCe”)
  22. Crock C, Olsson C, Phillips R, et al. General anesthesia or conscious sedation for painful procedures in childhood cancer: The family’s perspective. Arch Dis Child 2003;88(3):253-7.
  23. American Academy of Pediatric Dentistry. Informed consent. Pediatr Dent 2017;39(6):397-9. 
  24. American Academy of Pediatrics Committee on Bioethics. Informed consent, in decision-making in pediatric practices. Pediatrics 2016;138(2):e20161484. 
  25. Sfikis P. A duty to disclose: Issues to consider in securing informed consent. J Am Dent Assoc 2003;134(10):1329-33. 
  26. Frankel RI. The Papoose Board and mothers’ attitudes following its use. Pediatr Dent 1991;13(5):284-8.
  27. Southern Association of Institutional Dentists. Managing maladaptive behaviors—the use of dental restraints and positioning devices. Self-study course; Module 6: 1-24. Available at: “http://saiddent.org/admin/images/035 67700_1339447006.pdf”. Accessed January 28, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6sk4my5es”)
  28. Fenton SJ. Revisiting the issue of physical restraint in dentistry. Spec Care Dentist 1989;9(6):183.
  29. British Society of Paediatric Dentistry. British Society of Paediatric Dentistry: A policy document on the use of clinical holding in the dental care of children. 2016. Available at: “http://bspd.co.uk/Portals/0/BSPD%20clinical%20holding%20guidelines
    %20final%20with%20flow%20chart%20250416.pdf ”. Accessed August 7, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6sk587DPL”)
  30. Vessey JA, Carlson KL, McGill J. Use of distraction with children during an acute pain experience. Nurs Res 1994;43(6):369-72.
  31. Fein JA, Daugherty RJ. Restraint techniques and issues. In: King C, Henretig FM, eds. Textbook of Pediatric Emergency Procedures, 2nd ed. Philadelphia, Pa., Lippincott Williams and Wilkins; 2008:15-22.
  32. Weddell JA, Sanders BJ, Jones JE. Dental problems of children with special health care needs. In: Dean JA, ed. McDonald and Avery’s Dentistry for the Child and Adolescent, 10th ed. St. Louis, Mo. Mosby Elsevier; 2016:519-22. 
  33. McWhorter AG, Townsend JA. Behavior Symposium Workshop A Report-Current Guidelines/Revision. Pediatr Dent 2014;36(2):152-3.
  34. Kemp F. Alternatives: A review of non-pharmacologic approaches to increasing the cooperation of patients with special needs to inherently unpleasant dental procedures. Behav Anal Today 2005;6(2):88-108.
  35. Friedman C. Treatment considerations: Alternative behavioral support strategies. In: Raposa KA, Pearlman SP, eds. Treating the Dental Patient with a Developmental Disorder. Hoboken, N.J. Wiley-Blackwell; 2012:73-95.
  36. Lyons RA. Treatment considerations: Behavioral supports. In: Raposa KA, Pearlman SP, eds. Treating the Dental Patient with a Developmental Disorder. Hoboken, N.J. Wiley-Blackwell; 2012:43-72.
  37. Tesini D, Fetter C. D-Termined Program© of Repetitive Tasking and Familiarization in Dentistry (DVD). Hampton, N.H.: Specialized Care Co.; 2004. 
  38. Tesini DA. The D-Termined Program© of familiarization and repetitive tasking. Practical Reviews in Pediatric Dentistry 2010;24(4):30 (Audio).
  39. Al Humaid, J, Tesini, D, Finkelman, M, Loo, CY. Effectiveness of the D-Termined Program© of repetitive tasking for children with autism spectrum disorder. J Dent Child 2016;83(1):16-21. 
  40. Chen HY, Yang H, Chi HJ, Chen HM. Physiologic and behavioral effects of papoose board on anxiety in dental patients with special needs. J Formos Med Assoc 2014;113(2):94-101.
  41. Shapiro M, Sgan-Cohen HD, Parusa S, Melmed RN. Influence of adapted environment on the anxiety of medically treated children with developmental disability. J Pediatr 2009;154(4):546-50.
  42. de Castro, AM, de Oliveira FS, de Paiva Novaes MS, Araujo Ferreira DC. Behavior guidance techniques in pediatric dentistry; Attitudes of parents of children with disabilities and without disabilities. Spec Care Dentist 2013;33(5):213-7.
  43. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry 2003;48(5):330-7. 
  44. Spreat S, Lipinski D, Hill J, Halpin ME. Safety indices associated with the use of contingent restraint procedure. Appl Res Ment Retard 1986;7(4):475-81. 
  45. Adair SM, Durr DP. Modification of Papoose Board® restraint to facilitate airway management of the sedated pediatric dental patient. Pediatr Dent 1987;9(2):163-5. 
  46. American Dental Association. Principles of Ethics and Code of Professional Conduct. With official advisory opinions revised to November 2016. Available at: “http://www.ada.org/~/media/ADA/Publications/Files/ADA_Code_of_Ethics_2016.pdf?la=en”. Accessed January 28, 2017.