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Authors: John Morgan, Bonnie F. Zimble

Special Considerations in Special Care Dentistry:

Supports and Health-related Protections

Special Care in Dentistry
John Morgan, DDS
Tufts University School of Dental Medicine, 2008


Study Questions:
 

  1. Define supports:

    1. In general (Massachusetts DMR definition)

    2. In dentistry, including the conditions under which supports are needed, and examples of supports

  2. Describe physical holding and limitations on health-related protections.

  3. Describe the various forms and conditions for the use of emergency restraints.

Note: The following information has been adapted from Massachusetts DMR regulation 115 CMR 5.12.

What are “supports?”  

According to Massachusetts DMR regulation 115 CMR 5.12, the term supports refers to:  

“…those resources and strategies that promote the interests and causes of individuals with or without disabilities; that enable them to access resources, information and relationships inherent in integrated work and living environments; and that result in their enhanced independence, productivity, community integration, and satisfaction.”

In dentistry, supports needed to achieve proper body positions, balance, or alignment, and health-related protections, are not emergency restraint. Supports may be used only to: 

  • Achieve proper bodily position and balance
  • Permit the individual to actively participate in ongoing activities without the risk of physical harm from those activities
  • Prevent re-injury during the time an injury is healing
  • Prevent infection of a condition for which the individual is being treated, or
  • Enable provider staff to evacuate an individual who is not capable of evacuation

Devices providing such support include but are not limited to:  

  • Orthopedically prescribed appliances
  • Surgical dressings and bandages
  • Protective helmets
  • Supportive body bands, and
  • Physical holding in a gentle manner for no more than five minutes

Health-Related Protections

Health-related protections are methods and strategies ordered by a physician or other authorized clinician if absolutely necessary during a specific medical or dental procedure or for the individual’s protection during the time that a condition undergoing treatment pursuant to that clinician’s orders exists.  These devices shall not be considered a type of restraint.

  1. Physical holding, which is and is not restraint.  If in order to physically hold an individual physical force is required to overcome his or her active resistance, then the holding is not a physical holding in a gentle manner nor a support or health-related protection (unless the holding is employed to evacuate an individual from his or her residence). Rather, it is an emergency restraint. Physical holdings necessary to evacuate an individual from his or her residence shall be deemed to be a support and not an emergency restraint, regardless of whether physical force is necessary to overcome the individual’s active resistance.
     
  1. Limitations on health-related protections and supports.  Health-related protections ordered by a physician or other authorized clinician for the individual’s protection during the time that a medical, dental, or other condition requiring treatment exists may be employed if authorized by the clinician.  Supports needed to achieve holding, including devices needed to achieve proper body position, balance, or alignment shall be authorized only if determined in the individual’s ISP to be the least restrictive means of achieving a therapeutic objective.  Where such determination is required, the ISP shall specify the device to be used, and the individual’s record shall contain the indications for use and discontinuance, the alternatives considered, the frequency and duration of use, procedures for safety checks, and the qualified professional supervising use of the device.
     
  1. Further limitations on supports.  Supports permitted shall be designed and applied:

(a)   With the authorization and supervision of a qualified practitioner;

(b)   In accordance with principles of good body alignment, concern for circulation, and allowance for change  of position.

Emergency Restraint 

1.     Definition of Terms shall have the following meaning:

Emergency shall mean that a reasonable person would perceive one or more of the following:

(a)   the present occurrence of serious self-injurious behavior;

(b)  the present occurrence of serious physical assault;

(c)   the imminent threat of serious self-injurious behavior or behavior which is likely to lead to self injury, where the individual has the present ability to effect such behavior and has engaged in any action which indicates a present intention or inclination to carry out such behavior immediately.

(d)  The imminent threat of serious physical assault, where the individual has the present ability to effect such assault and has engaged in any act which indicates a present intention or inclination to carry out such assault immediately.  The occurrence or imminent threat of property damage is not an emergency unless such damage is also likely to lead to the serious self-injury of the individual or to the serious harm of those present. 

Support needed to achieve proper body position, balance, or alignment means a limitation of movement necessary for the individual to achieve proper body position, balance, or alignment.  It is not a form of emergency restraint and may not be used for the convenience of staff. 

Transportation restraint shall mean limitation of movement necessary for the safety of the individual during transportation.  It is not a form of emergency restraint and may not be used for the convenience of staff. 

2.  Emergency Restraint – Requirements For Use.  The use of emergency restraint must conform to the requirements of the DMR.

(a)   Use Permitted Only in Emergency.  Emergency restraint – whether physical, mechanical, or chemical – may be used only in cases of emergency.

(b)  Least restrictive alternative.  Emergency restraint may be used only after the failure of less restrictive alternatives or after a determination, based upon professional judgment, that such alternatives would be ineffective under the circumstances.

(c)   Duration of emergency restraint.  Emergency restraint may be used only for the period of time necessary to accomplish its purpose, but in no event may physical or mechanical restraint be used beyond the periods.

(d)  Duration of transportation restraint.  Transportation restraint may be used only for the period of time necessary to accomplish its purpose and only during transportation.

(e)   PRN orders prohibited.  No “P.R.N.” or “as required’ authorization of restraint may be written.

3.  Chemical Restraint – Additional Requirements and Limitations on Use.

(a)   Authorization for use.  An individual may be given chemical restraint only on the order of an authorized physician who has determined that such chemical restraint is the least restrictive, most appropriate alternative available.  Such an order may not be implemented unless:

1 - the authorized physician giving the order is or was present at any time during the course of the emergency justifying the use of the restraint; or

2 - prior to issuing the order, the authorized physician has a telephone consultation with a physician, registered nurse or nurse practitioner, or certified physician assistant who is or was present at the tie and site of the emergency and who has personally examined the individual.

(b)  Chemical Relaxation for Medical or Dental Treatment.  Sedatives or anti-anxiety medication prescribed by a qualified practitioner for the sole purpose of relaxing or calming an individual so that he or she may receive medical or dental treatment is not a restraint.  Administration of such medication shall be deemed incidental to the treatment, and, except in a medical emergency, requires the consent of the individual or guardian.  Providers should incorporate into an individual’s ISP objectives that assist the individual to learn how to cope with medical treatments and that lead to the decrease or elimination of medication for chemical relaxation incidental to treatment. 

4.  Additional requirements and restrictions apply for use of Physical or Mechanical Restraint.  

   See the Mass. DMR regulations link above for more detailed information.