4.3 Special Needs Dentistry, Geriatric Care & Dental Management in Pregnancy

4.3 Special Needs Dentistry, Geriatric Care & Dental Management in Pregnancy

Special Needs Dentistry (SND), geriatric oral health, and dental management during pregnancy encompass diverse clinical considerations requiring tailored communication, non-invasive therapeutic interventions, and strict adherence to pharmacological safety frameworks.

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Special Needs Dentistry (SND) & Disability Management

Patients with intellectual disabilities (e.g., Down Syndrome, Autism Spectrum Disorder), neurodegenerative disorders, or physical disabilities (e.g., Cerebral Palsy, Multiple Sclerosis) face substantial barriers to oral healthcare and exhibit elevated rates of periodontal disease, untreated caries, and malocclusion.

Behavioural Adaptation & Communication Strategies

• Tell-Show-Do Technique: Verbally explain the procedure, demonstrate on a model or fingernail, and then perform the action.
• Sensory Modifications: Reduce ambient noise, dim overhead dental lights, utilize noise-cancelling headphones, and schedule appointments at quiet times of the day for patients with Autism Spectrum Disorder (ASD).
• Desensitisation Visits: Gradual introduction to the clinic environment over multiple short visits.
• Mouth Props & Physical Support: Soft rubber bite blocks (McKesson props) prevent involuntary jaw closure; supportive positioning pillows assist patients with severe spinal deformities or spasticity.

Drug-Induced Gingival Overgrowth

Three major drug classes induce gingival hyperplasia, complicating plaque control and requiring meticulous oral hygiene or surgical excision:

1. Anticonvulsants (e.g., Phenytoin): Incidence up to 50%; fibrotic, firm enlargement originating at interdental papillae.
2. Calcium Channel Blockers (e.g., Nifedipine, Amlodipine): Vascular, hyperaemic gingival enlargement.
3. Immunosuppressants (e.g., Ciclosporin): Highly vascular, friable gingival overgrowth common in transplant recipients.

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Geriatric Dentistry & Ageing Physiology

Geriatric dentistry addresses the complex interplay of physiological ageing, cognitive decline, polypharmacy, and dry mouth.

Xerostomia & Hyposalivation

Xerostomia (subjective dry mouth) and hyposalivation (unstimulated salivary flow $<0.1 ext{ mL/min}$) affect over 30% of older adults, primarily driven by polypharmacy (anticholinergics, antihypertensives, antidepressants, antihistamines, diuretics), head/neck radiotherapy, or Sjögren's Syndrome.

• Clinical Sequelae: Rapidly progressive root surface caries, acute oral candidiasis (erythematous/pseudomembranous), loss of denture retention, angular cheilitis, dysphagia, and burning mouth sensation.
• Therapeutic Management Matrix:
  • High-Concentration Fluoride: Prescribe 5,000 ppm Sodium Fluoride Toothpaste (NeutraFluor 5000 / Duraphat) for daily brushing.
  • Remineralising Adjuncts: Apply Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP / Tooth Mousse) daily to promote hydroxyapatite remineralisation.
  • Salivary Substitutes: Use mucin-based or carboxymethylcellulose-based artificial saliva sprays and gels.
  • Sialagogues: Systemic Pilocarpine (5 mg tds) may be prescribed if functioning salivary gland parenchyma remains.

Non-Invasive Management of Root Caries: Silver Diamine Fluoride (SDF)

In frail, institutionalised, or cognitively impaired geriatric patients, conventional cavity preparation is frequently unfeasible.

• 38% Silver Diamine Fluoride (SDF): Contains 25% silver (antimicrobial agent), 8% dicarboxylate/ammonia (solvent), and 5% fluoride (remineralising agent).
• Mechanism: Silver ions ($Ag^+$) denature bacterial proteins and inhibit dentine matrix metalloproteinases (MMPs), while fluoride ($F^-$) forms fluorhydroxyapatite.
• Clinical Application: Clean lesion, isolate, dry, apply 38% SDF for 1–3 minutes, rinse. Arrests active dentinal caries rapidly.
• Patient Counseling Note: SDF causes permanent black discolouration of carious dentine; healthy tooth structure remains unstained.

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Dental Management in Pregnancy & Lactation

Dental care during pregnancy requires balancing maternal oral health against fetal safety, avoiding teratogenic drugs, and managing anatomical displacement.

+---------------------------------------------------------------------------------------------------+
|                                 PREGNANCY TRIMESTER CLINICAL MATRIX                               |
|                                                                                                   |
|  1st Trimester (Wks 1-13)  ===> Organogenesis; Avoid non-essential drugs/x-rays; Emergency care  |
|  2nd Trimester (Wks 14-27) ===> OPTIMAL WINDOW for elective dental restorations & scaling         |
|  3rd Trimester (Wks 28-Term)===> Patient discomfort; Supine Hypotensive Syndrome risk; Left tilt  |
+---------------------------------------------------------------------------------------------------+

Supine Hypotensive Syndrome

In the third trimester, lying flat in the supine position causes the heavy gravid uterus to compress the Inferior Vena Cava (IVC) and abdominal aorta against the spine.

• Clinical Presentation: Sudden onset of pallor, dizziness, diaphoresis, nausea, arterial hypotension, and bradycardia.
• Emergency Intervention: Immediately tilt the patient 15 to 30 degrees onto her LEFT side (or place a wedge/pillow under her RIGHT hip) to shift the gravid uterus off the IVC and restore venous return.

TGA Pharmacological Safety Categories in Pregnancy

Dental Radiography Protocol in Pregnancy

With modern digital radiography, rectangular collimation, and lead aprons with thyroid collars, radiation exposure to the fetus is negligible ($<0.01 ext{ mGy}$, well below the 50 mGy teratogenic threshold). Necessary diagnostic radiographs for dental emergencies should never be withheld during pregnancy.