EPILEPSY &THEEPILEPSY &THEDENTAL DENTAL PATIENTPATIENT

NEUROGENIC DISORDER NEUROGENIC DISORDER

(EPILEPSY)(EPILEPSY) Neurogenic disorder of the brain.Neurogenic disorder of the brain.

Epilepsy:Epilepsy: Is the most common neurogenic Is the most common neurogenic disorder the dentist may face in his clinic.disorder the dentist may face in his clinic.

Potential problems:Potential problems:1.1. Precipitation of the attack.Precipitation of the attack.

2.2. Problems of Problems of drugsdrugs taken taken a) a) PhenytoinPhenytoin-------- Gingival ------ Gingival hyperplasia hyperplasia b) b) ValproateValproate-------- Bleeding tendancy------ Bleeding tendancy

Manifestations of Seizure Manifestations of Seizure Attack:Attack:

Isolated, brief seizureIsolated, brief seizure - Tonic-clonic movement of trunk & - Tonic-clonic movement of trunk &

extremitiesextremities - Loss of consciousness- Loss of consciousness - Vomiting- Vomiting - Airway obstruction- Airway obstruction - Loss of urinary & anal sphincter control- Loss of urinary & anal sphincter control Repeated or sustained seizure (Status Repeated or sustained seizure (Status

Epileptics)Epileptics)

A neurologic disorder characterized by A neurologic disorder characterized by Recurrent Episodes of Seizures.Recurrent Episodes of Seizures.

Grand mal seizure:Grand mal seizure: T Temporary loss of emporary loss of consciousness accompanied by uncontrollable consciousness accompanied by uncontrollable muscular contractions and relaxation.muscular contractions and relaxation. • Phase 1: AuraPhase 1: Aura• Phase 2: Loose consciousness Phase 2: Loose consciousness • Phase 3: Muscle contractionsPhase 3: Muscle contractions• Phase 4: Sleep/recoveryPhase 4: Sleep/recovery

Petit mal seizure:Petit mal seizure: B Brief lapse of rief lapse of consciousness that may last only a few consciousness that may last only a few seconds.seconds.

Epileptic SeizuresEpileptic Seizures

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

Seizure vs EpilepsySeizure vs Epilepsy

Seizures

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

Nonepileptic Epilepsy(Recurrent Seizures)

Idiopathic(primary)

Symptomatic(secondary)

Questions Raised by a First Questions Raised by a First SeizureSeizure

Seizure or not?Seizure or not?

Focal onset?Focal onset?

Evidence of inter - ictal CNS Evidence of inter - ictal CNS dysfunction?dysfunction?

Metabolic precipitant?Metabolic precipitant?

Seizure type? Syndrome type?Seizure type? Syndrome type?

Start AED?Start AED?

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 underlying genetic or May be due to underlying genetic or

congenital factors or to cerebral insult congenital factors or to cerebral insult prenatally or later in lifeprenatally 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

Types of EpilepsyTypes of Epilepsy

1- Partial Seizures1- Partial Seizures -Simple partial seizure

-Complex partial (Psychomotor) seizure

2.Generalized Seizures

- G. Absence seizure (Petit mal)

-Generalize tonic-clonic seizure (Grand mal)

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)

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 Complex = somatic complaints + AMS or

LOCLOC

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

First Aid - Tonic-Clonic SeizureFirst Aid - Tonic-Clonic Seizure Turn person on side with face turned Turn person on side with face turned

toward ground to keep airway clear, toward ground to keep airway clear, protect from nearby hazardsprotect from nearby hazards

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

DO NOT put any object in mouth or DO NOT put any object in mouth or restrainrestrain

ANTIEPILEPTIC DRUGSANTIEPILEPTIC DRUGS

Phenytoin Carbamazepine Sodium

Valproate Phenobarbital Primidone

Gabapentin Lamotrigine Topiramate Tiagabine Oxcarbazepine Levetiracetam Zonisamide Pregabalin

1st Generation

2nd Generation

Approach for 1Approach for 1stst Seizure, New Seizure, New Seizure, or Substance/ Trauma Seizure, or Substance/ Trauma

Induced SeizureInduced Seizure As always ABC’s First As always ABC’s First IV, O2, Monitor.IV, O2, Monitor.

Send blood for CBC, Chem, Tox screen as appropriateSend blood for CBC, Chem, 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:consciousness – Rx with: Lorazepam 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 ExamIncluding detailed Neuro Exam Repeat Neuro evaluations a must!Repeat Neuro evaluations a must!

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

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

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

Dental treatment of the E pileptic pati ents AEDs

1. Patient handling

-C hair position -P atient’s head -F alse teeth

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3 . Treatment planni ng

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A granulocytosis, Thrmbocytopenia

2. Signs of liver damage

4. Cosmetic effects: hirsutism, coarsening of face, widening of jaws, thickening of lips

3. Signs of lymphadenopathyttttttt-ttttttt tttttttt

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 minutes OR two seizures greater than 5 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