Demanding, manipulative and resistant behaviors may be seen in the person with mental retardation, the psychiatric patient, the patient with dementia, and even those with purely physical disabilities and normal mental function. These behaviors can interfere with the safe provision of dental treatment.
The family or caregivers must be utilized to prepare uncooperative patients for treatment according to their needs and desires, and to interpret for the dentist what the patients desires are.
Some behavior management strategies are:
- creating a caring empathetic relaxed environment
- scheduling appointments at the appropriate time of day
- behavior modification techniques
- positive reinforcement
- distraction via television or music
- desensitization
- voice control
- immobilization with protective devices and restraints
- sedation
- general anesthesia
Desensitization
Progressive desensitization may be effective with some anxious individuals. This modality should at least be attempted. The initial dental appointment can serve as an introductory visit in which no actual treatment is provided.
Physical restraint
The use of restraints is recognized as acceptable dental practice when appropriately applied to control behavior while administering dental care to patients with developmental disabilities.
Use of restraints should be documented in the progress notes. Also, the practitioner should consider the issue of informed consent before using behavior management techniques.
No consensus exists among the states regarding the definition of restraint or what constitutes the use of restraints. The astute practitioner should consult with the state dental board before establishing an office policy.
There are some areas of agreement regarding the use of restraints:
- should be used only when necessary
- the least restrictive alternative should be chosen
- restraint shall not be used as punishment
- restraint shall not be used for the convenience of the staff
- restraints should cause no physical injury to the patient
Restraint can be defined as “physical restraint” which refers to one person holding another person’s arms, legs or head to control movements and prevent self-injury by the patient. “Mechanical restraint” refers to the use of devices such as the Papoose boards, pedi-wraps, tape, straps, blankets and mouth props. “Chemical restraint” refers to sedation.
Sedation
Most patients with physical and mental disabilities can be routinely managed in the dental office with conventional techniques such as local anesthesia, and perhaps nitrous oxide conscious sedation. For some patients this approach is inadequate.
Sedation and behavior management should generally be accomplished in consultation with the patient’s physician, family and caregivers to determine the appropriate approach. In any case a step-wise approach should proceed from least restrictive to most restrictive methods.
Note: Many State Dental Boards require dentists to obtain certification to utilize sedative techniques such as IV sedation or general anesthesia.
Oral sedation with Valium, Xanax, chloral hydrate, or hydroxizine may be helpful in reducing patient anxiety during dental treatment. Considerations include:
- will patient take medications orally?
- who will administer medications?
- who will monitor the patient before, during and after the appointment?
- what are the potential drug interactions?
- have you consulted with the patient’s physician?
- has informed consent been obtained?
Intravenous sedation requires an appropriately trained team and appropriate monitoring equipment. The team must be prepared to respond to allergic, respiratory, and/or cardiac complications.
General Anesthesia
General anesthesia or deep sedation should be the last resort in the behavioral management armamentarium. However, for the most uncooperative patients, it is often the most ideal method. During general anesthesia an anesthesia team manages the patient’s medical status and vital signs while the dental team concentrates on the dental procedures.
Obviously, informed consent must be obtained from the mentally competent patient or the legal guardian. A physical examination and certain lab tests will be required prior to the administration of general anesthesia.
