Epilepsy/ dental courses

EPILEPSYEPILEPSY
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Terms related to seizuresTerms related to seizures
• Convulsion, seizure : defined in 1870 by Hughlings Jackson as “ a symptom…an
occasional , an excessive , and a disorderly discharge of nerve tissue.”
• Epilepsy derived from the greek term epilepsia, meaning to get hold off.
• WHO defines epilepsy as a chronic brain disorder of various etiologies characterized by
recurrent seizures due to excessive discharge of cerebral neurons.
• Tonic : a sustained muscular contraction; patient appearing rigid or stiff during the
tonic phase of the seizure.
• Clonic: intermittent muscular contraction or relaxation, the clonic phase being the
actual convulsive portion of the seizure
• Stertorous : characterized by snoring; used to describe breathing
• Ictus : a seizure

Partial seizuresPartial seizures
• Also called focal
• Types
• Simple partial
• Complex partial
• involve specific regions of the brain
• clinical signs and symptoms related to the ictal
focus
• Motor, sensory or both symptoms – simple
• If spells seen with hallucinations, déjà vu etc. -
complex

Generalized seizuresGeneralized seizures
• Types
• Grand mal
• Petit mal
• Psychomotor
• Grand mal (tonic clonic)
• Most common
• Genetic disposition, neurologic disorder/ secondary to systemic or
metabolic disturbances
• Last about 2-3 mins. Seldom more than 5 minutes (clonic phase)
• Total duration is 5 -15 minutes, return to preictal cerebral
function : 2 hrs.

Petit malPetit mal
• Absence seizures
• found associated with other forms of seizures
• Seen almost always during childhood to adolescence
between 3-15 yrs.
• Occur frequently, multiple episodes after awakening,
periods of inactivity.
• Brief lapse of consciousness for 5-10 seconds rarely
beyond 30 seconds.
• Petit mal triad
• Myoclonic jerks
• Akinetic seizures
• Blank spells without associate falling

Jacksonian epilepsyJacksonian epilepsy
• Simple partial seizure
• Consciousness maintained despite obvious
impairment
• Focal convulsions may be motor, sensory or
autonomic
• Begin in limbs as convulsive jerking, or
localised chronic spasms of the face
• Marches in an orderly manner

Psychomotor epilepsyPsychomotor epilepsy
• Complex partial seizure or temporal lobe epilepsy
• Involve extensive cortical regions
• Last longer 1-2 mins, more gradual onset and
termination
• Associated impairment of consciousness often
progressing to generalized seizures
• Common causes : birth injury, tumor and trauma
• Late childhood to early adulthood
• automatisms

Many known causes……Many known causes……• Two major categories
• Primary
• Secondary
• Primary : more than 65% epileptics cause is idiopathic/ genetic.
• Relatives of these patients report 3-5 % incidence rate
• Secondary (acquired): remaining 35% of individuals exhibit various causes as
• Congenital abnormalities
• Perinatal injuries
• Metabolic and toxic disorders
• Head trauma
• Tumors
• Infectious diseases
• Degenerative disorders
• Vascular diseases

In the dental office…In the dental office…
• Most common causes of any type ofMost common causes of any type of
seizureseizure
– seizure in an epileptic patientseizure in an epileptic patient
– HypoglycemiaHypoglycemia
– Hypoxia secondary to syncopeHypoxia secondary to syncope
– Local anesthetic overdoseLocal anesthetic overdose
www.indiandentalacademy.comwww.indiandentalacademy.com

Predisposing factorsPredisposing factors
• Some cases no apparent predisposingSome cases no apparent predisposing
factor, however some pointers helpfactor, however some pointers help
– Younger age group patientsYounger age group patients
– Acute triggers : flashing lights, fatigue, aAcute triggers : flashing lights, fatigue, a
missed meal, alcohol ingestion, physical ormissed meal, alcohol ingestion, physical or
emotional stressemotional stress
– Generalised metabolic or toxic disturbanceGeneralised metabolic or toxic disturbance
– Cerebrovascular insufficiencyCerebrovascular insufficiency

PreventionPrevention
• Nonepileptic causesNonepileptic causes
– Prevention difficult due to idiopathic naturePrevention difficult due to idiopathic nature
– Physical evaluation prior to treatmentPhysical evaluation prior to treatment
• Epileptic causesEpileptic causes
– Determine the probability of development ofDetermine the probability of development of
an acute seizurean acute seizure
– Team prepared to manage the event andTeam prepared to manage the event and
associated complicationassociated complication

HistoryHistory
Questionairre …..Questionairre …..
• Q : Circle any of the following that you have had or have at present:Q : Circle any of the following that you have had or have at present:
– Seizures or epilepsySeizures or epilepsy
– Fainting or dizzy spellsFainting or dizzy spells
• Q : Have you taken any drug or medicine for the past 2 yrs.Q : Have you taken any drug or medicine for the past 2 yrs.
• For positive responsesFor positive responses
Dialogue history …..Dialogue history …..
• What type of seizures do you suffer, how often and when was your lastWhat type of seizures do you suffer, how often and when was your last
seizure ?seizure ?
• What signals the onset of your seizure ?What signals the onset of your seizure ?
• How long do your seizures last ?How long do your seizures last ?
• Have you ever been hospitalized as a result of your seizure ?Have you ever been hospitalized as a result of your seizure ?

Dental therapy modifications……Dental therapy modifications……
• No clinical signs exist between seizure periodsNo clinical signs exist between seizure periods
• Psycho sedation : inhalation of nitrous oxide withPsycho sedation : inhalation of nitrous oxide with
20% O20% O22 safe for apprehensive patients.safe for apprehensive patients.
• Avoid over sedation if psycho sedativeAvoid over sedation if psycho sedative
techniques are usedtechniques are used
• Orally administered benzodiazepines for adultsOrally administered benzodiazepines for adults
and chloral hydrate/ midazolam for children.and chloral hydrate/ midazolam for children.
• Deep sedation via i.v./ i.m. route safe for moreDeep sedation via i.v./ i.m. route safe for more
fearful epileptics.fearful epileptics.
• Alcohol definite contraindicationAlcohol definite contraindication

Clinical manifestationsClinical manifestations
• Partial seizuresPartial seizures
– Simple partial when…Simple partial when…
• Consciousness is unalteredConsciousness is unaltered
• Fully alert while limbs jerk for several secondsFully alert while limbs jerk for several seconds
– Complex partial when…Complex partial when…
• Altered consciousnessAltered consciousness
• Show automatismsShow automatisms
• Reoriented slowly in 1 min, recovery in 3 minsReoriented slowly in 1 min, recovery in 3 mins

Petit malPetit mal
• 3 - 15 yrs.3 - 15 yrs.
• Abrupt onsetAbrupt onset
• Sudden immobility and blank stareSudden immobility and blank stare
• Simple automatisms, minor facial clonicSimple automatisms, minor facial clonic
movementsmovements
• Last for 5 – 30 secondsLast for 5 – 30 seconds
• Abrupt return to normal activity with amnesiaAbrupt return to normal activity with amnesia

• Preictal phasePreictal phase
– Loss of consciousnessLoss of consciousness
– Most injuries sustained during this periodMost injuries sustained during this period
– Major myoclonic flexion jerksMajor myoclonic flexion jerks
– Epileptic cryEpileptic cry
– Autonomic changes like ↑ H.R., B.P, bladderAutonomic changes like ↑ H.R., B.P, bladder
pressure, superior ocular deviationpressure, superior ocular deviation

• Ictal phaseIctal phase
– Tonic component :Tonic component :
• sustained generalised skeletal muscle contractionsustained generalised skeletal muscle contraction
• Flexion followed by tonic rigidity of trunk and extremitiesFlexion followed by tonic rigidity of trunk and extremities
• Dyspnoea, cyanosis evidentDyspnoea, cyanosis evident
• Tonic rigidity lasts for 10 – 20 secondsTonic rigidity lasts for 10 – 20 seconds
– Clonic component :Clonic component :
• Heavy stertorous breathingHeavy stertorous breathing
• Alternating muscle relaxation and violent flexor contractionAlternating muscle relaxation and violent flexor contraction
• Frothing and bleeding in mouthFrothing and bleeding in mouth
• Lasts usually 2- 5 mins.Lasts usually 2- 5 mins.

• Post ictal phasePost ictal phase
– Tonic clonic movements ceaseTonic clonic movements cease
– Return to normal breathing and consciousnessReturn to normal breathing and consciousness
– Pt. is initially disoriented and confused may fall intoPt. is initially disoriented and confused may fall into
deep recuperative sleepdeep recuperative sleep
• Status epilepticusStatus epilepticus
– Continuous seizure for GTCS exceeding 5 minutesContinuous seizure for GTCS exceeding 5 minutes
– Life threatening situation persisting for hours or days.Life threatening situation persisting for hours or days.
– Pt. is unconscious, cyanotic with generalised clonicPt. is unconscious, cyanotic with generalised clonic
contractions with brief or absent tonic phase.contractions with brief or absent tonic phase.
– Hyperthermia upto 106Hyperthermia upto 106 00
F, b.p. 300/150 mm Hg.F, b.p. 300/150 mm Hg.

ManagementManagement
• Epilepsy is not a disease but a
symptom of periodic brain dysfunction.
• Focus on injury prevention and
adequate ventilation
• If seizure persists for more than 5 mins.
Anticonvulsant drug therapy to be
considered.

Petit mal and partial seizuresPetit mal and partial seizures
• Observe diagnostic clues
• Step 1 : terminate the procedure
• Step 2 :P ( position) neither time nor
need to alter patient position
• Step 3 : reassurance to patient
• Step 4 : discharge of the patient and
subsequent dental care

Grand Mal seizuresGrand Mal seizures
• Observe for diagnostic clues
• Preictal phase
• step 1 : terminate the procedure
• Ictal phase
• Step 2 : P ; place patient on floor in supine position or
chair in supine position
• Step 3 : summon medical assistance
• Step 4 : A-B-C ( airway- breathing- circulation)
• Step 5 : D ( definitive care)
1. Prevention of injury
2. Administration of O2
3. Monitoring vital signs

• Post ictal phase
• Step 6 : P (position)
• Step 7 : A-B-C
• Step 8 : monitoring vital signs
• Step 9 : reassurance to patient and
recovery
• Step 10 : discharge

Prosthodontic status and recommendedProsthodontic status and recommended
care of patients with epilepsycare of patients with epilepsy
Peter Kivovics, Pal Fejerdy, Katolin
Karolyhazy et al
J Prosthet Dent 2005;93: 177- 82.

Purpose of the studyPurpose of the study
• Examine the prosthodontic status of the
patients with epilepsy
• Determine the effect of the disease on the
prosthodontic treatment and obtain
information regarding level of prosthodontic
care
• Provide recommendations for prosthodontic
care

MethodologyMethodology
• 101 epileptic patients were examined, interviewed
and compared to 101 age matched control subjects
from the general population
• Dental classification of patients with epilepsy w.r.t the
frequency and no. of seizures
• Evaluation of the dental health status wrt
• the no. of missing teeth,
• ratio of missing to replaced teeth
• The no. of FPD, RPD and CDs and characteristics of
materials used
• State of oral mucosa and seizure related injuries

ResultsResults
• The no. of missing teeth significantly higher in
epileptic patients
• However ratio of replaced and missing teeth was
lower
• Average age of the fixed prostheses was significantly
lower in epileptics
• More epileptics ( 8) were edentulous at a younger
age ( 48 yrs vs. 57 yrs)
• Injuries were reported by 11% of patients all
belonging to subgroup of patients with frequent tonic
clonic seizures.

GuidelinesGuidelines
• Group 1 patients : should receive prosthodontic care
identical to general population
• Group 2 patients : observed in small number of
patients, no falls or forceful facial contractions .
Guidelines may be similar to group 3
• Group 3 patients : frequent GTCS patients
• Injury to teeth or prostheses highest
• Avoid occlusal ceramic inlays, prefer PFM crows
• Fixed prostheses preferred over removable
• Use of additional abutments advisable for more stability.
• Use large metal base for RPD and CDs over acrylic denture
base

conclusionconclusion
Epileptic patients have different needs
when developing prosthodontic
treatment plan.
Treatment should be individually tailored
based on type and severity of disease
Dentist should consider the history of
epilepsy with special emphasis on type
and frequency of seizures

Thank you

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