Guidelines for Medical Immobilization/Protective Stabilization for Your Practice
Allen Wong, DDS, EdD, DABSCD; Steven P. Perlman, DDS, MScD, DHL (Hon); H. Barry Waldman, DDS, MPH, PhD; and Rick Rader, MD
Many patients with special healthcare needs present to medical, dental, and other health visits with behavioral, emotional, postural, and psychological issues. According to the American Academy of Developmental Medicine and Dentistry (AADMD) guidelines from 2017, "Clinical dental treatment is the most exacting and demanding medical procedure that persons with special needs undergo on a regular basis throughout their lifetime."1 Moreover, dental treatment is basically surgical in nature, usually requiring controlled placement of sharpened instruments in intimate proximity to the face, airway, and highly vascularized and innervated oral tissues.2
When medically necessary healthcare must be provided and the patient's inability to accept or cooperate will compromise the quality of care the clinician will be able to deliver, interventions may be indicated and implemented. The pediatric literature is robust with information on basic to advanced behavioral techniques that are available to clinicians, but there is a paucity of information for adult patients. A continuum of behavioral guidance techniques has historically been established in healthcare settings with an approach that extends from least restrictive interventions, to medical immobilization/protective stabilization (MI/PS), to sedation, to general anesthesia. This model is also complicated by the public's perception that oral health is not an integral part of total health.
This is why MI/PS for medically necessary dental care has become one of the most contentious and controversial issues in dentistry and why the AADMD was charged with creating a "gold standard" policy of when, how, and why MI/PS can be and should be employed as the safest alternative to sedation and general anesthesia. Of most importance is the Academy's recognition that there should be only one set of guidelines for the use of MI/PS that encompasses all health professionals, whereas in the past guidelines existed solely for use in dentistry.
Medical immobilization/protective stabilization is defined as "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."3-7 Consistent with the United Nations' principles for the "protection of persons with mental illness and care and principles least intrusiveness and least restrictiveness," and as may be indicated with any patient, techniques that serve to desensitize a patient should always be employed prior to consideration of the use of stabilization, immobilization, or bracing of people. Furthermore, a full range of person-centered positive behavioral supports must be considered and utilized with people prior to, during, and after any application of stabilization, immobilization, or bracing.
Principles and Core Values
The full array of positive behavioral supports should be considered prior to, during, and following the application of stabilization techniques. Protective stabilization should, to the extent possible, be person-centered and conducted in a fashion that maintains the patient's privacy and dignity. Protective stabilization should be provided in the least restrictive manner possible. Staff should be trained in the safe, efficacious employment of any devices, techniques, or protocols. Their training requires documentation and evidence of competency-based training with refresher training based on frequency of use of stabilization techniques, confidence level, and self-assessment, but no less frequently than every 2 years. Patients should be monitored (health status) during and after the use of any protective stabilization. The use of protective stabilization requires documentation and should include the reason for the stabilization, any alternatives that were tried (where possible), members of the healthcare provider team involved, outcomes, and any recommendations for future use of the stabilization protocols with the patient.
Informed consent/ascent should be obtained. The intention to use protective stabilization should be communicated to the patients, parents, family members, legal guardians/conservators, direct care staff, or others responsible for the patient's care at the first available opportunity. Patients should be provided the rationale, risks, consequences, and expectations. The dialogue should be documented. (If the person is receiving long-term services and supports, it is likely appropriate to review any recommended use of stabilization with the person's interdisciplinary team. In addition, laws and applicable regulation should be consulted for involvement of human rights committees or their equivalent.)8-12
The AADMD believes that all individuals with intellectual or developmental disability deserve the highest quality of medical and dental care. To achieve this goal, clinicians must understand the cognitive, behavioral, sensory, reasoning, and experiential histories of the patient. There may be circumstances where it is reasonable to expect that a patient may not present as cooperative and compliant. (See World Health Organization Manual on Mental Health Law and Human Rights and Quality Rights.) Should there be a risk of the patient becoming agitated, unsteady, thrashing, contorted, flailing, or spasmodic with the potential for an unsuccessful outcome of the procedure with unhealthy consequences and/or the procedure having to be repeated or the results compromised, measured interventions should be taken that increase the opportunity for a successful procedure and outcome; this is preferred over moving to the surgical suite for general anesthesia and the inherent risks it provides. Sir William Osler, the doyen of American medicine, observed, "Do the kindest thing, and do it first." Often the kindest (and safest) thing is to stabilize and immobilize the patient to ensure a clinically successful procedure.
Indications, Benefits, and Contraindications
Protective stabilization is indicated when:
• a patient requires diagnosis and/or treatment and cannot be safely examined and/or treated without stabilization
• medical or dental treatment is needed, and uncontrolled movements risk the safety of the patient, staff, dentist, physician, nurse, aide, or parent without the use of protective stabilization
• a previously cooperative patient quickly becomes agitated during the appointment, in order to protect their safety and help to expedite completion of treatment
• a sedated patient becomes unexpectedly active during treatment
• a patient with special healthcare needs experiences uncontrolled movements that would be harmful or significantly interfere with the quality of care1
Protective stabilization is contraindicated for: compliant and cooperative non-sedated patients; patients with medical, dental, psychological, sensory, behavioral, psychiatric, or physical conditions that prevent them from being safely immobilized; and patients with a history of significant physical or psychological trauma due to previous restraints (unless no other alternatives are available).
When used correctly and in accordance with these guidelines, protective stabilization offers such benefits as providing the clinician with (as near as possible) an examination and operatory field with reduced untoward movements, protection for the patient and healthcare team, and a familiarity of expectations for the patient, which can help diminish future anxiety and promote healthcare visits.
Numerous devices are available to achieve protective stabilization (medical immobilization). The staff should be knowledgeable regarding the ideal characteristics of the devices they will be using. These devices should be easy to use, appropriately sized for the patient, soft and contoured to minimize potential injury and provide comfort to the patient, specifically designed for patient stabilization (no improvised equipment), and able to be sanitized and disinfected after each use. Mouth props may be used for oral and dental procedures as an immobilization device. The use of a mouth prop in a compliant patient is not considered protective stabilization. Hand guarding (the use of the clinician's hands and arms or those of the assistant) to provide adjunct stabilization can be employed as long as the hand guarding at no time restricts blood flow or respiration. Whenever possible the utilization of an approved desensitization program is always preferred to other stabilizing maneuvers.
The identical immobilization practices employed by physicians in emergency rooms, clinics, offices, and hospitals have been acknowledged as appropriate, beneficial, and required. One would be hard pressed to find lawsuits or medical board investigations directed at emergency room physicians who had an assistant hold a patient's arm while they started an intravenous line.
The AADMD's immobilization and stabilization policies and procedures represent the collective wisdom, sensitivity, and experience of this respected organization. Policy was created and approved as a living and evolving document, and the AADMD is positioned to address and consider new evidence that would impact the improvement of the policy.
The shift away from MI/PS toward pharmacologic management and techniques such as interim therapeutic restorations, which are not long-term solutions, is symptomatic of a large and concerning problem: the increasing numbers of dental professionals who lack the education or skills needed to guide the behaviors of children and adults with special healthcare needs in a positive direction.13 No substantial didactic or clinical dental curriculum regarding people with disabilities exists. Financial constraints are often cited as one of the most significant barriers in access to care.13
This article is adapted with permission, from Perlman SP, Wong A, Waldman HB, et al. "From restraint to medical immobilization/protective stabilization (MI/PS)," Dent Clin North Am. 2022;66(2):261-275.
About the Authors
Allen Wong, DDS, EdD, DABSCD
Professor and Director, Advanced Education in General Dentistry (AEGD)/Hospital Dentistry Program, University of the Pacific Arthur A. Dugoni School of Dentistry,
San Francisco, California
Steven P. Perlman, DDS, MScD, DHL (Hon)
Clinical Professor of Pediatric Dentistry,Boston University Goldman School ofDental Medicine, Boston, Massachusetts;Adjunct Faculty, University ofPennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
H. Barry Waldman, DDS, MPH, PhD
Distinguished Teaching Professor, School of Dental Medicine, Stony Brook University, Stony Brook, New York
Rick Rader, MD
Adjunct Professor, Human Development, University of Tennessee/Chattanooga, Chattanooga, Tennessee
1. American Academy of Developmental Medicine and Dentistry. Medical Immobilization Procedure Stabilization. AADMD website. August 2017. https://www.aadmd.org/.
2. Raposa KA, Perlman SP. Treating the Dental Patient with Developmental Disorder. Ames, IA: Wiley-Blackwell; 2012:44.
3. Townsend JA. Protective stabilization in the dental setting. In: Nelson TM, Webb JR, eds. Dental Care for Children with Special Needs. Springer Nature Switzerland AG; 2019:247-267.
4. American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry; 2021:306-324.
5. Karibe H, Umezu Y, Hasegawa Y, et al. Factors affecting the use of protective stabilization in dental patients with cognitive disabilities. Spec Care Dentist. 2008;28(5):214-220.
6. Marty M, Marquet A, Valera MC. Perception of protective stabilization by pediatric dentists: a qualitative study. JDR Clin Trans Res. 2021;6
7. Davis DM, Fadavi S, Kaste LM, et al. Acceptance and use of protective stabilization devices by pediatric dentistry diplomates in the United States. J Dent Child (Chic). 2016;83(2):60-66.
8. Ilha MC, Feldens CA, Razera J, et al. Protective stabilization in pediatric dentistry: a qualitative study on the perceptions of mothers, psychologists, and pediatric dentists. Int J Paediatr Dent. 2021;31(5):647-656.
9. Kemp F. Alternatives: a review of non-pharmacologic approaches to increasing the cooperation of patients with special needs to inherently unpleasant dental procedures. The Behavior Analyst Today. 2005;6(2):88-108.
10. Strange DM. The evolution of behavior guidance: a history of professional, practice, corporate and societal influences. Pediatr Dent. 2014;36(2):128-131.
11. Kupietzky A. Treating very young patients with conscious sedation and medical immobilization: a Jewish perspective. Alpha Omegan. 2005;98(4):33-37.
12. Frankl S, Shiere F, Fogels H. Should the parent remain with the child in the dental operatory? J Dent Children. 1962;29:150-163.
13. Killian C, Kupietzky A, Croll TP. Teaching behavior management of pediatric dental patients. Are we off track? Inside Dentistry. 2020;16(2):16-19.