EPILEPSY &THEEPILEPSY &THEDENTAL DENTAL PATIENTPATIENT

Manifestations of Seizure Manifestations of Seizure Attack:Attack:

Isolated, brief seizureIsolated, brief seizure - Tonic-clonic movement of trunk & extremities- Tonic-clonic movement of trunk & extremities - Loss of consciousness- Loss of consciousness - Vomiting- Vomiting - Airway obstruction- Airway obstruction - Loss of urinary & anal sphincter control- Loss of urinary & anal sphincter control

Epilepsy :Epilepsy : Recurrent seizures attacks Recurrent seizures attacks

Repeated or sustained seizure (Status Repeated or sustained seizure (Status Epileptics)Epileptics)

Seizure vs EpilepsySeizure vs Epilepsy

Seizures

CardiovascularDrug relatedSyncopeMetabolic (glucose, Na, Ca, Mg)Toxic (drugs, poisons)InfectiousFebrile convulsionsPseudoseizureAlcohol/drug withdrawalPsychiatric disordersSleep disorders (cataplexy)

Nonepileptic Epilepsy(Recurrent Seizures)

Idiopathic(primary)

Symptomatic(secondary)

EpilepsyEpilepsy Definition:Definition: a a state of recurrent seizuresstate of recurrent seizures, ,

not due to an identifiable metabolic causenot due to an identifiable metabolic cause May be due to :May be due to :

Underlying genetic or congenital factors Underlying genetic or congenital factors Cerebral insult prenatally or later in lifeCerebral insult prenatally or later in life

Background:Background: 1 – 2% of the general population has seizures1 – 2% of the general population has seizures PrimaryPrimary

Idiopathic epilepsy: onset ages 10-20Idiopathic epilepsy: onset ages 10-20 SecondarySecondary

Precipitated by one of the following:Precipitated by one of the following: Intracranial pathologyIntracranial pathology

Trauma, Mass, Abscess, InfarctTrauma, Mass, Abscess, Infarct Extracranial PathologyExtracranial Pathology

Toxic, metabolic, hypertensive, eclampsiaToxic, metabolic, hypertensive, eclampsia

Causes of EpilepsyCauses of Epilepsy

Seizure TypesSeizure Types Generalized Convulsive Seizures (Grand Generalized Convulsive Seizures (Grand

Mal):Mal): Tonic , clonic movements, (+) LOC, apnea, Tonic , clonic movements, (+) LOC, apnea,

incontinence and a post ictal stateincontinence and a post ictal state Non Convulsive Seizures (Petit Mal)Non Convulsive Seizures (Petit Mal)

BBrief lapse of consciousness that may last rief lapse of consciousness that may last only a few seconds.only a few seconds.

Absence seizures – “blank staring spells”Absence seizures – “blank staring spells” Myoclonic – brief contractions of selected Myoclonic – brief contractions of selected

muscle groupsmuscle groups Partial SeizuresPartial Seizures

Characterized by presence of hallucinationsCharacterized by presence of hallucinations Simple = somatic complaints + no LOCSimple = somatic complaints + no LOC Complex = somatic complaints + AMS or LOCComplex = somatic complaints + AMS or LOC

Types of EpilepsyTypes of Epilepsy

Epilepsy PrecipitantsEpilepsy Precipitants What might cause an otherwise stable patient to have a What might cause an otherwise stable patient to have a

seizure?seizure? Forgetting to take anticonvulsantForgetting to take anticonvulsant Stress –Emotional/PhysicalStress –Emotional/Physical Sleep disturbanceSleep disturbance HypoglycaemiaHypoglycaemia Alcohol withdrawalAlcohol withdrawal

Other medicationsOther medications Anticonvulsants – withdrawal from – esp. benzodiazepinesAnticonvulsants – withdrawal from – esp. benzodiazepines AntidepressantsAntidepressants AntipsychoticsAntipsychotics AntihistaminesAntihistamines AntibioticsAntibiotics CNS stimulantsCNS stimulants

Theophylline, caffeine, cocaine, amphetamineTheophylline, caffeine, cocaine, amphetamine Nonsteroidal anti-inflammatory agentsNonsteroidal anti-inflammatory agents OpiatesOpiates

Epilepsy : Potential Epilepsy : Potential problems:problems:

1.1. Precipitation of the attack.Precipitation of the attack.

2.2. Problems of Problems of drugsdrugs taken taken

a)a) PhenytoinPhenytoin-------- Gingival hyperplasia ------ Gingival hyperplasia

b)b) ValproateValproate-------- Bleeding tendancy------ Bleeding tendancy Most epileptic seizures are self-limited .Most epileptic seizures are self-limited . If more than 1 seizure—consider the If more than 1 seizure—consider the

possibility of underlying abnormality—possibility of underlying abnormality—e.g.e.g. electrolyte disturbance, hypoglycaemiaelectrolyte disturbance, hypoglycaemia

Status Epilepticus :Status Epilepticus : Seizures that are Seizures that are prolonged—prolonged—i.e.i.e. longer than 10 minutes or longer than 10 minutes or that re-occur without the patient regaining that re-occur without the patient regaining normal consciousnessnormal consciousness

Approach for SeizureApproach for Seizure Turn person on side with face turned toward ground to keep Turn person on side with face turned toward ground to keep

airway clear, protect from nearby hazardsairway clear, protect from nearby hazards DO NOT put any object in mouth or restrainDO NOT put any object in mouth or restrain As always ABC’s First As always ABC’s First IV, O2, Monitor.IV, O2, Monitor.

Send blood for CBC, Chemistry, Tox screen as appropriateSend blood for CBC, Chemistry, Tox screen as appropriate Anticonvulsant levelsAnticonvulsant levels Prolactin levels / Lactate levelsProlactin levels / Lactate levels

For seizures that are prolonged—For seizures that are prolonged—i.e.i.e. longer than 5 minutes or longer than 5 minutes or that re-occur without the patient regaining normal that re-occur without the patient regaining normal consciousness – Rx with: Lorazepam consciousness – Rx with: Lorazepam

Is patient still seizing? Post ictal? Pseudoseizure?Is patient still seizing? Post ictal? Pseudoseizure? Complete History and Physical ExamComplete History and Physical Exam

Including detailed Neuro ExaminationIncluding detailed Neuro Examination Repeat Neuro evaluations a must!Repeat Neuro evaluations a must!

Transfer to hospital needed for:Transfer to hospital needed for: Multiple seizures or status epilepticusMultiple seizures or status epilepticus Person is pregnant, injured, diabeticPerson is pregnant, injured, diabetic New onset seizuresNew onset seizures

Medical Treatment of First Medical Treatment of First Seizure(s)Seizure(s)

•Whether to treat first seizure is controversial ?

•16-62% will recur within 5 years

•Relapse rate for second seizure is reduced by AEDs,

BUT long term prognosis of whether the patient will have refractory epilepsy is not

•Increased risk of relapse

Abnormal imaging

Abnormal neurological exam

Abnormal EEG

Family history of epilepsy

•Currently, most patients are not treated for the first seizure unless there is an increased risk for relapse

ANTIEPILEPTIC DRUGSANTIEPILEPTIC DRUGS

Phenytoin Carbamazepine Sodium

Valproate Phenobarbital Primidone

Gabapentin Lamotrigine Topiramate Tiagabine Oxcarbazepine Levetiracetam Zonisamide Pregabalin

1st Generation

2nd Generation

After seizure attackAfter seizure attack

1.1. Place on side and suction Place on side and suction airwayairway

2.2. Monitor vital signsMonitor vital signs3.3. Initiate BLSInitiate BLS4.4. Administer OAdminister O22

5.5. Prepare to ERPrepare to ER

1.1. Diazepam 5mg/min IVDiazepam 5mg/min IV2.2. Midazolam 3mg/min IV or Midazolam 3mg/min IV or

IMIM3.3. Phenytoin10~15mg/kg IVPhenytoin10~15mg/kg IV

1.1. Suction airwaySuction airway2.2. Monitor vital signsMonitor vital signs3.3. Administer OAdminister O22

4.4. OBSERVE for at least OBSERVE for at least 1hr and consult 1hr and consult physicianphysician

Patient UnconsciousPatient Unconscious Patient ConsciousPatient ConsciousIf su

sta

ined

If su

sta

ined

Dental treatment of the E pileptic pati ents AEDs

1. Patient handling

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Prevention of Peri-operative Prevention of Peri-operative SeizuresSeizures

Patients must take their anticonvulsant Patients must take their anticonvulsant medicationmedication

If general anaesthetic – anaesthetist should be If general anaesthetic – anaesthetist should be aware of seizure tendencyaware of seizure tendency

Check patient’s pre-operative anticonvulsant Check patient’s pre-operative anticonvulsant levelslevels

Consult with patient’s neurologist or family Consult with patient’s neurologist or family physicianphysician

Most stable epileptics, well-controlled on Most stable epileptics, well-controlled on medication, can undergo surgery without medication, can undergo surgery without difficulty or complicationdifficulty or complication

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A granulocytosis, Thrmbocytopenia

2. Signs of liver damage

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Valproate & Lamotrigine

- - Stevens Johnson syndrome

- Stevens Johnson syndrome (valproate),

nausea, ataxia

Status EpilepticusStatus Epilepticus

DefinitionDefinition Operationally defined as seizure lasting Operationally defined as seizure lasting

greater than 5-10 minutes OR two seizures greater than 5-10 minutes OR two seizures

between which there is incomplete recovery between which there is incomplete recovery

of consciousness.of consciousness. ““Recurrent seizures with failure to Recurrent seizures with failure to

recover from one seizure before next recover from one seizure before next seizure begins”seizure begins”

Status EpilepticusStatus Epilepticus A medical emergencyA medical emergency Adverse consequences can include hypoxia, Adverse consequences can include hypoxia,

hypotension, acidosis and hyperthermiahypotension, acidosis and hyperthermia

Goal: stop seizures as soon as possibleGoal: stop seizures as soon as possible

HypoxiaHypoxia Lactic acidosisLactic acidosis HypercarbiaHypercarbia RhabdomyolysisRhabdomyolysis HyperpyrexiaHyperpyrexia HypoglycaemiaHypoglycaemia

Hypertension Hypertension (early)(early)

ArrhythmiasArrhythmias Neurogenic Neurogenic Hypotension (late)Hypotension (late) AspirationAspiration Injury, burns etcInjury, burns etc

AetiologyAetiology TumourTumour Cerebrovascular disease Cerebrovascular disease Head injuryHead injury Infection Infection Hypoxic encephalopathyHypoxic encephalopathy Drug abuse / overdose / withdrawalDrug abuse / overdose / withdrawal Metabolic Metabolic Primary epilepsy Primary epilepsy PseudoepilepsyPseudoepilepsy

TreatmentTreatment ABC & oxygen & IV accessABC & oxygen & IV access Glucose if indicated or unsure (50mls/D50 Glucose if indicated or unsure (50mls/D50 Diazepam or lorazepam IV (or PR)Diazepam or lorazepam IV (or PR) Phenytoin (to terminate SE or prevent further Phenytoin (to terminate SE or prevent further

fits)fits) Monitor ECG and BPMonitor ECG and BP Investigate & monitor (EEG)Investigate & monitor (EEG) Persistent: Persistent:

> Further phenytoin > Further phenytoin > Phenobarbitone > Phenobarbitone

> Thiopentone > Thiopentone Propofol Propofol

PrognosisPrognosisDepends onDepends on AetiologyAetiology AgeAge Duration of statusDuration of status Systemic complications (anoxia)Systemic complications (anoxia) Treatment givenTreatment given

Mortality: 3 – 35%Mortality: 3 – 35%

Responding to a Patient Experiencing a Responding to a Patient Experiencing a ConvulsionConvulsion

After seizure attackAfter seizure attack

1.1. Place on side Place on side and suction and suction airwayairway

2.2. Monitor vital Monitor vital signssigns

3.3. Initiate BLSInitiate BLS4.4. Administer OAdminister O22

5.5. Prepare to ERPrepare to ER1.1. Diazepam 5mg/min IVDiazepam 5mg/min IV2.2. Dormicum 3mg/min IV or Dormicum 3mg/min IV or

IMIM3.3. Dialantin 10~15mg/kg IVDialantin 10~15mg/kg IV

1.1. Suction airwaySuction airway2.2. Monitor vital Monitor vital

signssigns3.3. Administer OAdminister O22

4.4. OBS for at least OBS for at least 1hr and consult 1hr and consult physicianphysician

Patient unconsciousPatient unconscious Patient consciousPatient consciousIf susta

ined

If susta

ined

Seizures vs EpilepsySeizures vs Epilepsy

Definition:Definition: the clinical the clinical manifestation of an manifestation of an abnormal and abnormal and excessive excitation of excessive excitation of a population of cortical a population of cortical neuronsneurons

Incidence:Incidence: approximately approximately 80/100,000 per year80/100,000 per year

Lifetime prevalence:Lifetime prevalence: 9% 9% (1/3 benign febrile (1/3 benign febrile convulsions)convulsions)

Definition: a tendency toward recurrent seizures unprovoked by systemic or neurologic insults

Incidence: approximately 45/100,000 per year

Point prevalence: 0.5-1% 14 years or younger

13% 15 to 64 years

63%65 years and older

24%

Cumulative risk of epilepsy through 74 years old: 1.3% - 3.1%

Seizures Epilepsy

STROKE and TIASTROKE and TIA Cerebrovascular disease is the most common Cerebrovascular disease is the most common

cause of neurologic disability in Western cause of neurologic disability in Western countriescountries

Major types of cerebrovascular disease:Major types of cerebrovascular disease: Cerebral insufficiencyCerebral insufficiency InfarctionInfarction HaemorrhageHaemorrhage Arteriovenous malformationArteriovenous malformation Stroke = Ischaemic lesionsStroke = Ischaemic lesions

TIA = transient ischaemic attackTIA = transient ischaemic attack Focal neurologic abnormalities of sudden Focal neurologic abnormalities of sudden

onset and brief duration (usually minutes, onset and brief duration (usually minutes, never more than a few hours) that reflect never more than a few hours) that reflect dysfunction in the distribution of either the dysfunction in the distribution of either the internal carotid-middle cerebral or the internal carotid-middle cerebral or the vertebral-basilar arterial systemvertebral-basilar arterial system

StrokeStroke

80% involve the carotid system80% involve the carotid system 33rdrd leading cause of death in US and Canada leading cause of death in US and Canada Major cause of disabilityMajor cause of disability Most stroke survivors die of myocardial diseaseMost stroke survivors die of myocardial disease

Stroke – Unmodifiable RisksStroke – Unmodifiable Risks

Age – majority occur in individuals >65Age – majority occur in individuals >65 Male genderMale gender Race – higher incidence in African AmericansRace – higher incidence in African Americans HeredityHeredity

Stroke – Modifiable RisksStroke – Modifiable Risks

HypertensionHypertension Diabetes mellitusDiabetes mellitus Cigarette smokingCigarette smoking AlcoholAlcohol ObesityObesity HyperlipidaemiaHyperlipidaemia Cardiac disease – esp. previous myocardial Cardiac disease – esp. previous myocardial

infarction and atrial fibrillationinfarction and atrial fibrillation Haematologic factors – Haematologic factors – e.g.e.g.

hyperhomocystinaemiahyperhomocystinaemia

Treatment of Acute StrokeTreatment of Acute Stroke

In a non-post-operative patient, tPA (tissue In a non-post-operative patient, tPA (tissue plasminogen activator) can be given plasminogen activator) can be given intravenously within 3 hours of onset of stroke intravenously within 3 hours of onset of stroke symptoms and intra-arterially within 6 hourssymptoms and intra-arterially within 6 hours

The best treatment is preventionThe best treatment is prevention

Stroke PreventionStroke Prevention

Risk factor modificationRisk factor modification AspirinAspirin

Dose between 81 and 325 mg/dayDose between 81 and 325 mg/day Ticlopidine (TiclidTiclopidine (Ticlid®)®) Clopidogrel (Plavix®)Clopidogrel (Plavix®) ASA/persantine (Aggrenox®)ASA/persantine (Aggrenox®)

WarfarinWarfarin

Stroke and SurgeryStroke and Surgery For elective surgery – delay for 2-3 months post-For elective surgery – delay for 2-3 months post-

eventevent Do not stop ASA or antiplatelet agentDo not stop ASA or antiplatelet agent Remember high incidence of ischaemic coronary Remember high incidence of ischaemic coronary

artery disease in patients with TIA or strokeartery disease in patients with TIA or stroke Surgical trauma associated catecholamine release Surgical trauma associated catecholamine release

leads to platelet activationleads to platelet activation Platelet activation promotes platelet aggregation Platelet activation promotes platelet aggregation

and hypercoagulabilityand hypercoagulability Aspirin is not routinely started in the immediate Aspirin is not routinely started in the immediate

peri-operative periodperi-operative period Even in high risk patients already taking aspirin, it Even in high risk patients already taking aspirin, it

is generally discontinued a week prior to elective is generally discontinued a week prior to elective surgery to improve intra-operative hemostasissurgery to improve intra-operative hemostasis

Stroke and SurgeryStroke and Surgery The risk-to-benefit ratios of administering The risk-to-benefit ratios of administering vsvs withholding withholding

aspirin in the immediate peri-operative period have never aspirin in the immediate peri-operative period have never been assessed and comparedbeen assessed and compared

There are no large randomized controlled trials available to There are no large randomized controlled trials available to guide usguide us

WHAT DOES THE LITERATURE SAY?WHAT DOES THE LITERATURE SAY? Gaspar et al. – Department of Oral and Maxillofacial Gaspar et al. – Department of Oral and Maxillofacial

Surgery, Rambam Medical Center, HaifaSurgery, Rambam Medical Center, Haifa CONCLUSION:CONCLUSION: discontinuing low-dose aspirin prior to discontinuing low-dose aspirin prior to

elective oral surgery is not justifiedelective oral surgery is not justified Harefuah 1999 136:108-10Harefuah 1999 136:108-10

Sonksen Sonksen et al. – et al. – Dept. of Anaesthesia, City Hospital, Dept. of Anaesthesia, City Hospital, Birmingham, UKBirmingham, UK

Conclusion: Conclusion: in healthy volunteers the defect in in healthy volunteers the defect in haemostasis has largely disappeared 48 hours after the last haemostasis has largely disappeared 48 hours after the last dosedose British Journal of Anaesthesia 1999 82:360-5British Journal of Anaesthesia 1999 82:360-5

Aspirin and SurgeryAspirin and Surgery Bartlett – Department of Plastic, Reconstructive, Bartlett – Department of Plastic, Reconstructive,

Hand and Maxillofacial Surgery, Middlemore Hand and Maxillofacial Surgery, Middlemore Hospital, Auckland, New ZelandHospital, Auckland, New Zeland

Conclusion: Conclusion: it is unnecessary to stop aspirin before it is unnecessary to stop aspirin before minor dermatologic plastic surgeryminor dermatologic plastic surgery British Journal of Plastic Surgery 1999 52:214-6British Journal of Plastic Surgery 1999 52:214-6

Ardekian et al. – Department of Oral and Ardekian et al. – Department of Oral and Maxillofacial Surgery, Rambam Medical Center, Maxillofacial Surgery, Rambam Medical Center, Haifa, IsraelHaifa, Israel

Conclusion:Conclusion: low-dose aspirin should not be stopped low-dose aspirin should not be stopped before oral surgerybefore oral surgery Journal of the American Dental Association 2000 131: Journal of the American Dental Association 2000 131:

1398, 1401-21398, 1401-2