A patient with Down syndrome has a history of being difficult to manage in the dental setting. Which intervention is CONTRAINDICATED?

Correct answer: A. Physical (protective) restraint

• A. CORRECT. PHYSICAL RESTRAINT is contraindicated because of ATLANTOAXIAL INSTABILITY, present in roughly 10–20% of individuals with Down syndrome. Forceful positioning or head/neck restraint risks cervical cord compression and catastrophic neurologic injury. Deep sedation and general anesthesia also require special caution for the same reason, plus the associated congenital cardiac disease, macroglossia, and airway hypoplasia.
• B. Rubber dam is HELPFUL in this population — it protects the airway, controls the tongue, and improves moisture control. It should be used when tolerated.
• C. Nitrous oxide is a reasonable and widely used adjunct, provided the patient can breathe nasally, which may be limited by the chronic nasal congestion common in this population.
• D. Local anesthesia is safe and appropriate; there is no Down-syndrome-specific contraindication.