management epileptic patient in dental office

1. Management of epileptic
patients

2. • The word “epilepsy” is derived from the Greek
• word “epilambanein” meaning to take or to
seize.

3. • 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

4. • 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.

5. • 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

6. • The most common cause of adult epilepsy is
• cerebrofollowed by primary and metastatic
brain tumors.vascular disease (stroke, brain
attack)

7. • 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.

8. • Epilepsy pathogenesis, at the cellular level,
• relates to systems that maintain the balance
• between excitation and inhibition of brain
• electrical activity

9. classification

10. • 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.

12. • 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

13. Considerations for the Dental management of
the 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.

14. • 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

15. • 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

16. 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)

18. Questions to be asked of dental
patients with epilepsy.

19. • 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.

20. • 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).

21. • 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.

22. • 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.

23. • 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.

24. • 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

25. • 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

26. If the seizure

27. If seizure, when we need medical
attention

28. 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.

29. • 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

30. • 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.

31. • 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;

32. • 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

33. • 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

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

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

36. • 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

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

38. • 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.

39. 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.

40. 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.