Does Protective Stabilization of Children During Dental Treatment Break Ethical Boundaries? A Narrative Literature Review Geovanna de Castro Morais MACHADO 1 , Ana Paula MUNDIM 2 , Mauro Machado do PRADO 3 , Cerise Castro CAMPOS 3 , Luciane Rezende COSTA 4 1 Dentistry Graduate Program, Universidade Federal de Goias (UFG), Goiania-GO, Brazil. 2 Faculty of Dentistry, Instituto Tocantinense Presidente Antônio Carlos Porto (ITPAC), Porto Nacional-TO, Brazil. 3 Department of Oral Prevention and Rehabilitation, Faculty of Dentistry, Universidade Federal de Goias (UFG), Goiania-GO, Brazil. 4 Department of Oral Prevention and Rehabilitation, Faculty of Dentistry, Universidade Federal de Goias (UFG), Brazil Abstract Aim: Protective stabilization, a method for immobilizing or reducing the ability of a patient to freely move his or her body, raises ethical concerns that should be discussed. This narrative literature review aimed to discuss the bioethical aspects involved in the use of protective stabilization in normally developed children who exhibit behavior management problems in dental care. Methods: A critical review of full papers retrieved from PubMed, LILACS, SCIELO, BBO, supplemented by specialist books, the Brazilian Civil and Criminal Codes, the Brazilian Code of Dental Ethics, and institutional guidelines. Results: The literature indicates that the decision to use protective stabilization in normal children during dental treatment can be based on bioethical principlism, according to the principles of beneficence, non-maleficence, autonomy, and justice. The fears and limitations of a child must be respected and aversive physical impositions should be avoided. When a child does not cooperate with dental treatment, protective stabilization may be indicated with the written consent of parents and for specific procedures of short-duration, such as dental emergencies. Other options for managing the child's behavior in these cases are postponing care or indicating pharmacologic methods. The continuous use of protective stabilization is not justified in elective treatments. Conclusion: The use of protective stabilization in pediatric dentistry breaks ethical boundaries if the dentist is not trained in the application of the method, does not analyze the risks, benefits, and potential harm of the method, insists on its use for several appointments and for non-emergency procedures, does not respect the parents’ opinion and the child’s autonomy (even though in construction), and does not consider local law. Key Words: Dental care for children, Physical restraint, Physical immobilizatio, Infant behaviour, Child behaviour, Behavior management, Bioethical issues Abbreviations PubMed: United States National Library of Medicine database’, LILACS: Literatura Latino-Americana em Ciências da Saúde, SCIELO: Scientific Electronic Library Online, BBO: Biblioteca Brasileira de Odontologia, AAPD: American Academy of Pediatric Dentistry, UK: United Kingdom, UNESCO: United Nations Educational, Scientific and Cultural Organization Introduction In pediatric dentistry, as well as in other health areas, fear, anxiety, and behavior management problems can be observed when performing procedures in children, such as immunization, lumbar puncture, and dental care. Fear is an emotional response to a specific threatening stimulus [1]. Anxiety is the feeling that something terrible will happen and it is associated with feelings of loss of control [1]. The knowledge and experience of the dentist in dealing with an uncooperative or pre-cooperative child defines the problems of behavior management, which directly reflects on the outcome of dental treatment [1]. The prevalence of dental fear and anxiety in children and adolescents ranges from 5.7 to 19.5% and in relation to behavior management problems the range is from 8.0 to 10.5% [1]. The etiology of these emotional problems in dentistry is multifactorial [1,2], and a trained dentist should manage them through the use of communicative techniques such as tell–show–do and distraction [3]. Dentists who deal with children should be aware of their role in preventing avoidance behavior, by stimulating patients’ adaptation to dental treatment through sequential visits [4]. However, in young children this conditioning effect might be negatively influenced by local anesthesia and/or dental procedures [5]. Then, sometimes children cry, scream, and struggle in an attempt to get off the dental chair. In such cases, there is a need to manage the child's behavior, often with more coercive techniques to enable quality of care such as the immobilization of the child, currently known as "protective stabilization". Protective stabilization (synonyms: physical restraint, physical contention) is the restriction of a patient’s freedom to move independently, aiming to reduce the risk of injury during care and so improve the quality of dental treatment [3]. The restriction of the movements of the patient's body and limbs can be made with the aid of persons (active restraint) or of devices that involve the child's body (passive restraint) [6]. Protective stabilization requires the written informed consent of the parents or the legal guardians [3,6]. Over the last decade, the use of immobilization of mentally disabled patients has been restricted to emergency situations that must be resolved quickly so as not to cause health risks to the patient [7]. For children with normal development, the use of protective stabilization in pediatric dentistry has also been seen differently in recent years, because societies worldwide understand children’s rights and emotions in differente ways [3,6]. So, in today's world, health professionals are challenged to provide more humanitarian health care for both children Corresponding author: Prof. Luciane Rezende Costa, Faculdade de Odontologia, Avenida Universitária, esquina com 1ª. Avenida, Setor Universitário, Goiânia-GO, CEP 74605-220, Brazil; Tel: (62)3209-6047; Fax: (62) 3209-6325; e-mail: lsucasas@ufg.br 188