Patients with Limited Communicative Ability
Parents’ Role in Treatment
There is controversy among practitioners whether parental presence in the treatment area hinders or aids in patient behavior management. Nowak writes separation anxiety from parents in children occurs around 6 months of age, peaks between 13 and 18 months of life and then declines. Casamissimo and Adair write that maternal presence is needed especially during stress between the ages of 3 and 5 years. The child’s ability to separate from the parent is dependent on various social and developmental factors.19
A survey of the AAPD members found that the majority of respondents indicated parents were present in the operatory routinely for emergency examination (61%) and procedures involving special needs children (66%). Thirty eight percent thought the desire of parents to be present in the operatory had increased in the last 5 years.19 In a recent study by Shroff on pediatric dental patients’ parents, 78% of parents surveyed wanted to be present during their child’s dental treatment for comfort, while only 38% were okay with the dentist determining if they should be present or not.20
In summary, parents were allowed in the room if the patient had limited communicative ability because of chronologic age (under three years) or special needs. The necessity for parent presence for patients between ages three to five years varied with the patient’s emotional needs and complexity of treatment. Other factors included the dentist’s comfort level with parental presence, and whether the parent’s presence had a positive or negative effect on the patient’s behavior.
Patients with Limited Communicative Ability
Patients under 18 months of age with limited communicative ability are most effectively treated with physical restraint. However, in light of the discussion in the previous section, the restraint must be administered in a non-traumatic manner. Since children at this age are still very attached to parents, the parent should be actively involved in the restraint wherever possible. The following techniques will permit such participation.
Examination of the young patient with limited communicative abilities is best performed in the “knee-to-knee” position in a private office or quiet area. The dentist and parent sit opposite one another with knees touching. The child sits in the lap of and facing the parent with their legs embracing the parent’s lap. While the parent is holding the patient’s hands, the child lays backward with the head resting in the dentist’s lap. This position enables the child to see and feel the parent while the dentist performs the examination with minimal restraint. The position allows for excellent visualization of the oral cavity by both the parent and dentist.
Products such as pillows and lap cushions are available to facilitate the knee-to-knee lap exam.
An alternative technique is to allow the child to sit in the parent’s lap. This position increases patient cooperation by increasing the security of the child. Note the parent restrains the patient’s upper body with their arms and hands and the lower body by crisscrossing the legs.
Advanced Behavior Guidance
The use of protective stabilization devices (papoose board) may be indicated in instances where the patient requires immediate diagnosis, urgent care, and/or limited treatment and cannot cooperate due to emotional or cognitive developmental levels, lack of maturity, or mental or physical conditions; a patient who requires immediate diagnosis, urgent care, and/or limited treatment and uncontrolled movements risk the safety of the patient, staff, dentist, or parent without the use of protective stabilization; and sedated patients to help reduce untoward movements. Proper documentation for protective stabilization includes indications, type of stabilization, informed consent, reason for parental exclusion during protective stabilization (when applicable), the duration of application, behavior evaluation/rating during stabilization, any untoward outcomes (such as skin markings), and management implications for future appointments.
If the previous non-pharmacological techniques are insufficient to adequately restrain and treat the uncooperative patient, the dentist may have to turn to sedation or general anesthesia if they possess the proper training or refer to those that do, to provide the necessary treatment.