Survey of the utilization of and rationale for hand-over-mouth (HOM) and restraint in postdoctoral pedodontic education.

A questionnaire was sent to allpostdoctoralpedodontic training programs in the United States to survey the teaching of certain behavior management echniques. The responses indicated widespread acceptance of both restraint and hand over mouth techniques. A behavioralpsychological explanation is offered which describes these techniques as "response prevention’" oriented and as methods to be used in response to a child’s "avoidance" behavior. The effects of the proper use of hand-over-mouth and restraint are described and explained as are potential deleterious effects of several alternative approaches. Recommendations are made as to the optimum approach for various difficult-to-manage children. The techniques are discussed from a contemporary behaviorist viewpoint. When a young child displays highly disruptive, tantrum-like behavior in the dental office, the practitioner needs techniques for managing the child in a quick, effective, and positive manner. A variety of relevant behavior management techniques which meet this need have been described in the literature, among them restraint 1-3 and hand-over-mouth (HOM). 4’5 This paper addresses two aspects of these techniques: {1) current teaching in advanced pedodontic education, and (2) the behavioral-psychological tenets and effects of these techniques. To establish the contemporary utilization of these behavior modification techniques, a brief questionnaire was distributed to the advanced pedodontic training programs in the United States. Of 62 questionnaires, 36 were returned (58%). The questions and responses are listed in Fig. 1. The three most frequent responses are listed where applicable, as is the percentage of respondents replying. Totals do not equal 100% where multiple responses are possible. It appears from these responses that the techniques of restraint and HOM continue to be taught in almost 90% of the postdoctoral programs. Since no simple alternative management techniques are widely known, it may be inferred that these measures are resultantly in widespread use in the private practice of pedodontics. This is in keeping with the practitioner survey of management techniques conducted by the American Academy of Pedodontics in 1972.7 Further, it is probable that these techniques are employed in predoctoral pedodontic education as represented by the responding postdoctoral programs. Thus, they are implemented in the general practice of dentistry for children. Questions two and three indicate that the HOM technique, as delineated subsequently, is generally structured after the guidelines of Craig4 and Levitas. ~ Question four demonstrates that restraint is generally accepted in certain situations. Questions five and six concern the anticipated psychological effects of these techniques and the preparation of the student to identify such effects. The responses to these two questions indicate general agreement that negative effects of restraint and HOM are nonexistant or minimal. Elucidation of the psychological mechanisms of these techniques is needed. Specifically, is the belief generally held that essentially only positive results occur, explainable via contemporary psychological theory? The discussion that follows attempts to provide such an explanation. Most undesirable behavior in the dental environment can be classified as "avoidance" responses. 8 The child may have learned this particular mode of response to selected experiences by several methods, two of which are most relevant for the dental setting. {1) The child arbitrarily does not want to comply with any behavioral requests. He is resorting to actions which in the past have succeeded in enabling him to avoid selected situations. This behavior is a generalized learned response elicited by similar environmental stimuli. (2) The child is responding fearfully to den-