Management of epileptic patients

• The word “epilepsy” is derived from the Greek

• word “epilambanein” meaning to take or to seize.

• Modern medicine defines epilepsy as a• chronic neurological disorder characterized• by frequently recurrent seizures. A seizure is• a sign of a disease, which manifests as an• episodic disturbance of movement, feeling, or• consciousness caused by sudden synchronous,• inappropriate, and excessive electrical discharges• that interfere with the normal functioning of the• brain.2

• Etiology and Pathogenesis

• In approximately 70% of all cases the specific

• cause of seizures cannot be determined. These cases are classified as idiopathic or primary

• epilepsy. When the cause of the seizure is

• known, the terms used are either acquired or

• secondary epilepsy.

• The reason for secondary

• epilepsy can be metabolic, structural, and

• functional abnormalities including seizures

• secondary to head trauma, especially if

• consciousness was lost for more than 30 minutes

• The most common cause of adult epilepsy is

• cerebrofollowed by primary and metastatic brain tumors.vascular disease (stroke, brain attack)

• Systemic disorders that can cause epilepsy• include infections, hypertension, and diabetes as• well as electrolyte imbalances, dehydration, and• lack of oxygen. High doses and withdrawal from• chronic use of drugs such as heroin, cocaine,• barbiturates, amphetamines, and alcohol can• also lead to seizures. There appears to be a• genetic predisposition to epilepsy associated with• chromosome 12 anomalies. These anomalies• increase the risk of epilepsy in children of• epileptic women.

• Epilepsy pathogenesis, at the cellular level,

• relates to systems that maintain the balance

• between excitation and inhibition of brain

• electrical activity

classification

• Other Medical Conditions Resembling• Epilepsy• Several disorders can often be mistaken for an• epileptic seizure: hyperventilation, hypoglycemia,• migraine, transient ischemic attacks, syncope,• pseudoseizure, transient global amnesia, and• sleep disorders. Of these, the most common• conditions confused with epilepsy are syncope,• pseudoseizure, and panic attacks.

• Medication Indications (seizure type) Most common oral side effects and dental considerations

• Phenobarbital Partial and secondarily generalized Drowsiness/sedation, osteopenia/ocsteomalaia

• Carbamazepine Partial and secondarily generalized Xerostomia, stomatitis, gingival bleeding, rash, osteopenia/osteomalacia

• Phenytoin Partial and secondarily generalized Gingival hyperplasia, gingival bleeding, osteopenia/osteomalacia

• Valproate or valproic acid Partial and generalized Gingival bleeding, petechiae, decreased platelet aggregation

• Primidone Partial and generalized Drowsiness/sedation• Lamotrigine Partial and generalized Rash• Topiramate Partial and generalized Mild cognitive side effects• Clobazam Partial and generalized Drowsiness/sedation• Oxcarbazepine Partial and secondarily generalized Unknown• Ethosuximide Generalized Drowsiness/sedation• Vigabatrin Partial Unknown• Lorazepam Generalized Drowsiness/sedation• Diazepam Generalized Drowsiness/sedation• Gabapentin Partial Drowsiness/sedation• Levetiracetam Partial and generalized Unknown

Considerations for the Dental management ofthe Epileptic Patient

• Unlike non-epileptic patients, specific

• considerations for epileptic patients include the

• treatment of oral soft tissue side effects of their

• medication and correcting damage to their teeth

• that has occurred secondary to seizure trauma.

• Dental treatment planning must consider the

• fabrication of a dental prosthesis designed to

• minimize risk of future damage or displacement

• of teeth. properly educated and instructed in oral hygiene

• and provided an understanding of how their oral

• health impacts their general healthThe epileptic patient should also be

• The two primary problems compromising the

• ability to maintain good oral health for patients

• with epilepsy are the financial resources to afford

• good healthcare and, in some patients, mental

• or physical handicaps which prevent them from

• being properly managed or to cooperate in a

• general dental setting

Dental management

• Most patients with epilepsy know they have the

• disease and are either on medication or know

• they are vulnerable to seizures. This information

• should be elicited during their initial visit

• ( case history)

Questions to be asked of dental patients with epilepsy.

• The intention of such questions is to derive a• complete picture of the patient’s health. This• includes evaluating the impact of epilepsy in• their lives, identifying any oral problems, and• minimizing the risk of their having an epileptic• seizure during a dental visit. The information also• assists in managing and treatment planning for• the patient to minimize any oral or health risks in• the future.

• As with all patients,• the frequency of dental• check-ups and prophylaxis appointments should• be based on the patient’s needs. The goal is to• decrease and prevent dental and periodontal• disease and diseases of the oral mucosa. The• recall and hygiene interval may be more frequent• for epileptic patients due to increased risk for• gingival hyperplasia secondary to use of an AED• such as phenytoin (Dilantin).

• The clinician should keep in mind stress is

• one of the factors that can trigger a seizure.

• Appointments should be scheduled during a time

• of day when seizures are less likely to occur, if

• predictable, and to minimize stress and anxiety

• during the appointment.

• Techniques such as

• explaining the dental procedures to the patient

• before starting and offering assurance and

• support during the procedure are always useful.

• This interaction allows the clinician to assess the

• status of the patient during the procedure and can

• reduce the patient’s worry and tension.

• Light can be a trigger in inducing an epileptic

• seizure. Therefore, dark or colored glasses can

• be used as eye protection and the operating lightmust be controlled so it is directed only into the mouth and not flashed into the patient’s eyes.

• Patients whose seizure activity does not

• respond to anticonvulsants may have to have

• a consultation with a neurologist prior to a

• dental appointment. Such patients may require

• additional anticonvulsant or sedative medication

• The use of conscious sedation and general

• anesthesia is not contraindicated in patients

• with epilepsy. In some situations nitrous oxide or

• intravenous sedation may be necessary to safely

• and effectively provide dental care

If the seizure

If seizure, when we need medical attention

Problems that a Dentist May Encounter

• Trauma

• Generalized tonic–clonic seizures often cause minor oral injuries, such as tongue biting,16 but also frequently lead to tooth injuries17 and in some cases to maxillofacial trauma.18

• Patients with epilepsy can be at increased risk of fracture because enzyme-inducing antiepileptic drugs (e.g., phenytoin, phenobarbital, carbamazepine) alter the metabolism and clearance of vitamin D and have been associated with osteopenia and osteomalacia.

• Of interest, increased fracture risk has also been associated with the use of benzodiazepines, antidepressants and antipsychotics, suggesting that underlying brain disease or adverse effects of the medication are responsible for falls and injuries

• Periodontal Problems• Gingival overgrowth as a complication of phenytoin use has

been well studied.21,22 About 50% of patients taking this medication will develop gingival hyperplasia within 12–24 months of initiation of treatment. Despite the existence of newer medications that are equally effective and have fewer side effects, phenytoin remains one of the most commonly used drugs. Evidence regarding best treatment for gingival hyperplasia is lacking. Some clinicians advocate the use of chlorhexidine, folic acid rinses or both, but excellent oral hygiene will probably prevent or significantly decrease the severity of the condition. In severe cases, surgical reduction is needed.

• Valproic acid can cause direct bone marrow suppression, which can impair wound healing and increase post-operative bleeding and infections. Decreased platelet count is the most common and best-recognized hematologic effect of valproic acid;

• Prosthodontic Problems

• such as discouragement of incisal restorations, use of fixed rather than removable prostheses and inclusion of additional abutments if fixed partial dentures are to be used.15 In addition, the use of metal base for complete dentures and telescopic retention with denture bases made of metal or reinforced with metal for nearly edentulous patients was recommende

• Dermatologic Problems

• Rash is a common side effect of antiepileptic drugs. Although most drug-associated rash is benign, serious rashes, including Stevens–Johnson syndrome and toxic epidermal necrolysis do occur

Drug Interactions

• A number of drugs prescribed by dentists can jeopardize seizure control because they interact with anti-epileptic drugs

• metronidazole, antifungal agents (such as fluconazole) and antibiotics (such as erythromycin) may interfere with the metabolism of certain antiepileptic drugs.

• The coadministration of fluconazole and phenytoin is associated with a clinically significant increase in phenytoin plasma concentration, and the dose of the latter may require adjustment to maintain safe therapeutic concentrations. Other anticonvulsants, such as vigabatrin, lamotrigine, levetiracetam, oxcarbazepine and gabapentin, are unlikely to interact with fluconazole

• Clarithromycin increases the plasma concentration of carbamazepine, and coadministration of these drugs should be monitored very carefully to avoid carbamazepine toxicity

• Valproic acid may be displaced from plasma proteins and metabolic pathways may be inhibited by high doses of aspirin; this interaction will free serum valproate concentrations resulting in subsequent toxicity.

Seizure First Aid in the Dental Office

• If a seizure occurs while a patient is in the dental chair • 1. Clear all instruments away from the patient. • 2. Place the dental chair in a supported, supine position as near to the floor as

possible. • 3. Place the patient on his or her side (to decrease the chance of aspiration of

secretions or dental materials in the patient’s mouth). • 4. Do not restrain the patient. • 5. Do not put your fingers in his or her mouth (you might be bitten). • 6. Time the seizure (the duration of the event may seem longer than it actually is). • 7. Call 911 if the seizure lasts longer than 3-5 minutes. • 8. Call 911 if the patient becomes cyanotic from the onset. • 9. Administer oxygen at a rate of 6–8 L/minute. • 10. If the seizure lasts longer than 5minute or for repeated seizures, administer a

10-mg dose of diazepam intramuscularly (IM) or intravenously (IV), or 2 mg of ativan, IV or IM, or 5 mg of mid-azolam, IM or IV.32,33

• 11. Be aware of the possibility of compromised airway or uncontrollable seizure.

Once the seizure is over

• 1. Do not undertake further dental treatment that day. • 2. Try to talk to the patient to evaluate the level of

consciousness during the post-ictal phase. • 3. Do not attempt to restrain the patient, as he or she

might be confused. • 4. Do not allow the patient to leave the office if his or her

level of awareness is not fully restored. • 5. Contact the patient’s family, if he or she is alone. • 6. Do a brief oral examination for sustained injuries. • 7. Depending on post-ictal state, discharge the patient

home with a responsible person, to his or her family physician or to an emergency room for further assessment.