Modification of Papoose Board restraint to facilitate airway management of the sedated pediatric dental patient.

Transitory loss of airway patency in sedated pediatric dental patients is generally managed easily by extending the patient's head and neck to restore an open airway. This procedure can be difficult if the patient is restrained in a rigid support, such as a Papoose Board®. Modification of the small Papoose Board to allow extension of the head is accomplished by cutting off the upper 89 inches of the support and reattaching it with a piano hinge and rivets. J. he use of physical restraint in the management of certain types of children in the dental setting is a well documented, accepted technique (Kelly 1976; Pinkham 1982; Wright et al. 1983). In a survey of 120 diplomates of the American Board of Pediatric Dentistry, 101 responded that they used restraint in "selected cases" (Association of Pedodontic Diplomates 1972). Patients with mental retardation and neuromotor dysfunction, or those displaying aggressive and resistant behavior were most frequently cited as requiring consideration for restraint. Troutman et al. (1982) also suggested that restraint be utilized when sedative premedication is employed, and a survey of postdoctoral pediatric dentistry programs revealed that restraint frequently was used for the premedicated patient (Davis and Rombom 1979). Of the various forms of total body restraint available, the Papoose Board" is particularly popular. It is available in 3 sizes and can be used with removable head stabilizers. Wright et al. (1983) stated that it offers the advantages of usually controlling the hands and preventing the child from squirming. Kelly (1976) noted that it can create hyperthermia in very active patients. Lynch et al. (1983) echoed this concern, and also pointed out that the flaps covering the chest make • Olympic Surgical Co; Seattle, WA. it difficult to monitor respirations. They suggested use of a stethoscope for this function. Another disadvantage of the Papoose Board is the fact that its flat, rigid design does not conform to the shape of some dental chairs (Lynch et al. 1983; Wright et al. 1983). The rigid design also can interfere with attempts to extend the head and neck to maintain airway patency in sedated children. Houpt et al. (1986) noted reduced gas exchange in some sedated patients who were restrained in a Papoose Board for dental restorations. They attributed this to inadvertent depression of the mandible which created a partial blockage of the airway. Chest movements continued unchanged during these episodes. Clinical experience also indicates that sedated patients may undergo partial blockage of the airway as relaxation of the musculature of the pharynx and tongue allow the tongue FIG 1. Towels positioned under the shoulders and neck of patients in a Papoose Board extend the head and maintain a patent airway. PEDIATRIC DENTISTRY: June 1987/Vol. 9 No. 2 163 FIG 2. A. f top) Front of modified Papoose Board with hinge in place. B. Rear view showing placement of hinge and cutouts for snaps which hold cloth restraints. to drop posteriorly. This is analogous to the transient hypoxia (sleep apnea) periodically suffered by chronic snorers. In fact, snoring by a sedated patient is recognized as a sign of partial airway blockage by the tongue. The situation usually is rectified by extending the head and neck to open the airway. One way to prevent this from occurring in patients restrained in a Papoose Board is to place folded towels under the neck and shoulders of the patient (Fig 1). This procedure may be difficult to accomplish' with an uncooperative patient, and such a safety measure may have to be delayed until the patient is effectively sedated. The following modification of the small (regular) Papoose Board may prove useful as a means of allowing head and neck extension in dental chairs with articulated head rests.