Factors influencing parental acceptance toward the use of passive immobilisation as behaviour guidance in children during dental treatment: a scoping review

2.1 Search strategies

Table 1 illustrates how the review was structured using a PCC question (Population, Concept and Context) recommended for scoping reviews by the Joanna Briggs Institute. From 20 August 2022 to 05 September 2022, a literature search was conducted in PubMed, Web of Science, Science Direct, EBSCO Host Medline Complete and Scopus with the results evaluated based on their content and relevance. The phrases “parental acceptance” OR “parental attitude” AND “passive restraint” OR “passive immobilization” OR “passive stabilisation” OR “protective stabilisation” OR “papoose board” OR “behaviour guidance” OR “behaviour management approach” were searched in the databases. Table 2 summarises the search phrases that were utilised. Similar search phrases were also used to find any significant papers in the following journals: Paediatric Dentistry, European Archive of Paediatric Dentistry, Special Care in Dentistry, Journal of Indian Society Pedodontic and Preventive Dentistry, and Journal of Dentistry for Children. Because most of the articles published in these journals were relevant to this investigation, they were chosen. In addition, grey literature and Google searches were carried out.

2.2 Study identification and selection

Two independent reviewers assessed the significance and relevance of the selected literature based on its content and publication type (NSI and IWM). The publication type was then determined to ensure that only research articles published in English were included. Other sorts of articles, such as case studies, reviews, commentaries, editorial remarks, dissertations, and conference abstracts, were not considered. We omitted studies that did not utilised the term passive immobilisation explicitly, such as protective stabilisation or physical restraint, where the sort of restraining devices could not be determined.

After locating articles in the databases, they were imported into Thompson Reuters EndNote X6 software (Philadelphia, PA, USA), where duplicates were deleted. Based on the titles and abstracts of the papers, the eligibility criteria were utilised to do a preliminary screening. According to Fig. 1 for the PRISMA-ScR selection process flow diagram, the full text of publications was then examined to identify which articles were eligible for inclusion in the review. Disagreements among reviewers were rectified through discussions. A third reviewer (MYMP) was consulted when differences remained. A data extraction form was employed to extract study features such as the author(s), the year of publication, the country of origin of the study, the research design, the population, the concept, and the context. A narrative synthesis of the results was performed to address the objectives.

Fig. 1.Flowchart on literature search and study selection process. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; WOS: Web of Science.

3.1 Characteristic of the included studies

The publications featured in this study spanned between the years 1984 to 2022. Only two studies were published in 1984 [18, 19]. After a quinquennial period of silence, three studies from the United States begin to publish their findings on parental attitudes on behaviour management in paediatric dentistry in 1991 [20, 21, 22]. Following a study in 1992 [23], two studies in 1995 [24, 25], a study in 1998 [26] and 1999 [27] were published. In the millennial years, two publications were published in 2005 [12, 28], and one research was published in each of 2007 [29], 2008 [30] and 2010 [31]. Then, in 2012, authors from Asian countries began to contribute two researches [32, 33]. Around 25 of the 40 publications were published in the previous ten years, demonstrating an increase in interest in the use of passive immobilisation in dentistry settings.

As illustrated in Fig. 2, a total of 40 papers were reviewed, which slightly more than one-third (15 of 40) conducted in the United States. India was second with eight articles, followed by Iran and Saudi Arabia with three articles. Brazil, Germany, Israel and Malaysia, each with two articles. Greece, Japan, Spain, Thailand and Turkey each contributed one paper. Among all the papers reviewed, only five articles utilised sample parents with special healthcare needs originated from India [32], United States [25, 30], and Brazil [29, 34]. Three studies were comparing parents with disabilities and without disabilities [25, 32, 34]. The type of disabling condition includes physical disabilities such as cerebral palsy [29], and syndromic children with intellectual disabilities such as Down’s syndrome [25, 34], Autism Spectrum Disorder [30], and Intellectual Developmental Disability [29].

Fig. 2.Countries of primary studies’ subjects.

3.2 Type of passive immobilisation

Most of the studies (95%) included used full body restraining devices like Papoose Board and Pedi-Wraps to denote passive immobilisation technique. Three articles specified mouth prop devices as passive immobilisation instrument in their studies [32, 35, 36].

3.3 Factors influencing parental acceptance of passive immobilisation techniques

Factors influencing parental acceptance toward the use of passive immobilisation devices as behaviour guidance in children during dental treatment could be divided into three major categories which were parent influences, children characteristic, and type of dental procedures. The parental influences were subdivided into cultural, socio-economic, educational (socio-behavioural), and method of exposure while the children’s characteristics were age, cognitive level, and children with special health care needs.

3.4 Passive immobilisation ranking parental preferences

Exploration of 40 articles showed that the relative acceptability of passive immobilisation techniques has not shown much change over time and has lingered in the last and second last of ranking preferences from other BGT. However, ranking preferences among parents with disabilities increased to the second most preferred techniques [25, 29, 32, 34] even in comparison with GA which might be attributed due to potential systemic risk of anaesthetic agent particularly in children with medically compromised [34, 65]. It could be seen that the high acceptance level of protective stabilisation strategy was attributed to the fact that parents were more familiar with the use of restraining devices in medical and dental care, including the trust established between parents and professionals who work in the department as many patients have been monitored over long periods of time [34].

4.1 Strength of the study

To our knowledge, this is the first comprehensive scoping review that explores various factors influencing parental acceptance toward the use of passive immobilisation as behaviour guidance in children during dental treatment. Existing review articles have not discussed arguments regarding passive immobilisation relevancy instead as being considered as forgotten behaviour management technique. On the other hand, this scoping review was able to screen all publicly accessible resources worldwide. Although a systematic review cannot be conducted at the moment due to the scarcity of experimental studies in the context of outcome measures of parental acceptance toward passive immobilisation, this review followed a structured methodology that included the ranking preferences of BGT among parents and their confounding factors that influence parental mannerism. Thus, this article may be the most in-depth discussion regarding passive immobilisation techniques in dentistry.

4.2 Knowledge gap

The hierarchy of acceptability of the passive immobilisation has changed in some regards for the past several decades. Several studies of parental acceptance of this advanced BGT demonstrated differing views of parental attitudes. Earliest studies conducted in 1984 regarding papooe board stated that the parent unfavoured aggressive techniques and they believed that the use of passive immobilisation device was unacceptable in all dental procedures except for emergency exodontia [18, 19]. Approximately a decade after, papoose board still located at the lowest rank of parental acceptance regardless to group effect on the parental rating and randomised order of the videotapes used to introduce the BGT [20, 21]. Nevertheless, real time observation of the passive immobilisation device being applied to their own child showed that 90% of the mother approved the use of papoose board [22]. As the time evolved, higher acceptance rate was found with regard to positive verbal explanations by the dentist [28] and children with different disabilities [25, 29, 32, 34]. Tsuchihashi et al. [33] who monitored internal stress using electrocardiogram (ECG) in healthy children showed that passive immobilisation technique would not necessarily be a traumatic event in a short term. Papoose Board also known as sensory adaptation technique device that provide a calming effect in CSHCN and children with autism [30, 66]. In 2022, a study done in CSHCN showed that papoose board can be considered safe and has no discernible influence on the child’s physiological responses by the measurement of their blood pressure, heart rate, and oxygen saturation level [67]. There were limited studies that compared the acceptability of passive restraint among parents with healthy children versus CSHCN as the strategy was viewed as “aversive” technique and restricted by litigations and policies by certain countries. Passive immobilisation may not be equally accepted and vary widely in different parts of the world and the acceptance may be uniquely influenced by either race and ethnicity [40], cultural background [13, 39, 51], parenting style and parental anxiety [41].

Passive immobilisation is a contentious issue for dental practitioners. The professionals and lay media have described the use of papoose board as a “barbaric practice” that should be banned and may be seen as child abuse [9, 68]. The use of passive immobilisation devices was considered as a cold and non-humanised conduct that resembling the use of straightjackets by the psychologist [9]. This was consistent with research from other health services as well, where passive immobilisation is perceived as emotionally challenging among nurses [69]. Exploration of general dentist perspectives showed that the use of restraint evoked difficult ethical evaluations while making individual assessments [10]. In United Kingdoms and Nordic countries, protective stabilisation were no longer a legal method of care [70]. However, in Asian countries like Malaysia, there was no legislation on the use of passive immobilisation devices in dental settings. The only legislation on the use of passive immobilisation was in non-psychiatric settings, where it should only be considered in emergency situations or if deemed clinically appropriate and justified [71]. The principles of human right to health must be adhered to at all times and should not be used as a form of punishment [72].

The current review’s factors resulted in a suggestive preference checklist before implementing passive immobilisation as a behaviour guidance technique in paediatric dentistry (Table 3). This will assist the practitioner in considering and justifying passive immobilisation techniques as a viable choice for behaviour management in dentistry settings. Every time a passive immobilisation device is used, it is strongly advised that details such as indications, written consent, vital signs monitoring records (e.g., baseline, pre-operative, intra-operative and post-operative), length of use, and side effects be recorded.