Sir, we have recently completed an evaluation of a series of patients referred to a child and adolescent mental health service (CAMHS) for dental phobia and would like to share some of our findings with your readers. At the assessment interview, one child described being physically restrained during previous dental work. The others all described an experience of an adult they perceived they could not challenge drilling in their mouth. It seemed surprising that physical restraint had been used and I discussed this with the local community dental officer (CDO.) She reported that 'a fair proportion' of children referred to her with high levels of anxiety or phobia recalled an episode of physical restraint. A questionnaire was then sent to local dentists (n = 96) to determine the prevalence of restraint and other types of control techniques being used for anxious or non-compliant children.

Over 80% of dentists responded to the questionnaire, with 25% reporting that they asked family members to restrain children by their shoulders or arms (half used this technique at least each month) and 19% reporting that a member of the practice staff had been used to restrain the child (one third of these at least monthly.)

We were encouraged to discover that all those who completed the questionnaire used less threatening anxiety management techniques before restraint, such as distraction, counting through the procedure, and multiple appointments to put the child at ease. Unfortunately time and commercial pressure can limit the use of lengthy anxiety management techniques. Until recently, sedation or general anaesthesia was an option for these children, however the 2001 General Dental Council guidelines stated: 'A dentist who makes a decision to refer a patient for sedation without first exploring all aspects of pain and anxiety control is liable to a charge of serious professional misconduct.' This may be a factor leading to the use of restraint, but it is important to note these guidelines also stated: 'There can be no justification for intimidation, or, other than in the most exceptional circumstances, for the use of physical restraint in dealing with a difficult patient.' The recent revision of these guidelines in May 2005 is much less prescriptive and does not explicitly mention restraint. However the principles of dignity, choice and consent are highlighted and it is to be expected that all professionals would consider these in the treatment of every patient, including those under 18 years of age.

In view of these guidelines, and the extent of restraint use, it may be that one solution lies in increased training for dentists or joint working between dentists and CAMHS. This would facilitate more use of specialist anxiety management. Any resource and funding implications from an increase in the number of children referred to CAMHS would need monitoring, but it is not unreasonable to hope that these could be negotiated if it was deemed necessary to prevent children being restrained or sedated in breach of guidelines. It may be helpful for a named link worker from the local CAMHS team to work with CDOs and offer training and joint working.

There may be services that already have experience of joint working and it would be interesting to hear from them. Dentists working within such a service may find it helpful for planning treatment and maintaining therapeutic relationships with children.

In closing, we would like to thank Judith Bray, community dental officer, for her help in this work.