Prosthodontic status and recommended care of patients with epilepsy

Katalin Karolyhazy, DDS,a Peter Kivovics, DDS, PhD,b Pal Fejerdy, DDS, PhD,c and
Zsuzsanna Aranyi, MD, PhDd
Semmelweis University, Budapest, Hungary
Statement of problem. Epilepsy is a chronic disease that can affect oral health and prosthodontic status in
different ways. However, epilepsy is a condition of various etiologies and seizure types, and different patients
may have differing needs in prosthodontic care.
Purpose. The purpose of this study was to examine the prosthodontic status of patients with epilepsy to
determine if the disease has any effect on prosthodontic treatment and to obtain information regarding the level
of prosthodontic care. This information was used to provide recommendations for the prosthodontic treatment
of patients with epilepsy.
Material and methods. One hundred one epileptic patients were examined, interviewed, and compared with
101 age-matched control (nonepileptic) subjects of the general population. Epileptic patients were recruited at
an epilepsy outpatient clinic. The only exclusion criterion was a mental handicap severe enough to exclude
cooperation of the patient during a dental examination. Control subjects were recruited at a community
radiographic chest-screening clinic. Epileptic patients were first grouped according to dental risk factors and
dental manageability. Dental classification of patients with epilepsy considered the frequency and type of
seizures, as seizures may damage the teeth and dental prostheses. The number of missing teeth, the ratio of
missing and replaced teeth, and the number of fixed and removable partial dentures and complete dentures, and
the characteristics (material, degree of abrasion, and age) of the dentures was determined by dental examination.
Finally, the state of oral mucosa and the number of seizure-related injuries was noted. Statistical comparison of
the patient and the control group was performed, using the 2-tailed t-test for continuous variables and the chi-
squared test or Fisher’s exact test for categorical variables (a=.05).
Results. The number of missing teeth was significantly higher in the epilepsy group than in the control group
(P=.021). The ratio of replaced and missing teeth was lower in the epileptic group (P,.01), indicating
inadequate prosthodontic care. There was also a significant difference in the age of the fixed prostheses
(P=.0016), being lower in the epilepsy group, and in the material of fixed prostheses (P=.033), metal-ceramic
being more common in the control group. More epileptic patients were edentulous than control subjects
(8 versus 3) and the average age at the time of examination was younger (48 versus 57 years). Seizure-related
injuries were reported by 11% of patients, all belonging to the subgroup of patients with frequent generalized
tonic-clonic seizures.
Conclusion. Patients with epilepsy have an increased risk for loosing teeth and, furthermore, the
prosthodontic status of epilepsy patients was not as optimal as compared with the control group. Seizure-
related injuries to prostheses are also an issue, but only in those suffering from frequent generalized tonic-clonic
seizures. Therefore, the large majority of patients can and should receive prosthodontic treatment without
restrictions. For a smaller group of patients, however, certain restrictions apply, to prevent potentially dangerous
seizure-related complications. (J Prosthet Dent 2005;93:177-82.)

CLINICAL IMPLICATIONS
Epileptic patients have differing needs when developing prosthodontic treatment plans.
Treatment should be individually tailored, considering the type and severity of the disease. The
dentist should consider the history of epilepsy, with special emphasis on the type and frequency of
seizures.

a
Assistant Professor, Department of Prosthetic Dentistry, Faculty of
E pilepsy is a common neurological disorder with
a prevalence reaching 1%.1 It is characterized by recur-
Dentistry. rent episodes of abnormal synchronous discharge of
b
Associate Professor, Department of Prosthetic Dentistry, Faculty of the brain, resulting in various types of seizures.2 The
Dentistry. disease may affect the dental status and oral health of pa-
c
Professor, Department Head, Department of Prosthetic Dentistry,
Faculty of Dentistry.
tients in a number of ways: The seizures themselves can
d
Senior Assistant Professor, Department of Neurology, Faculty of cause injuries to the teeth and dental prostheses,3-6 cer-
Medicine. tain antiepileptic drugs can cause periodontal disease,7-9

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THE JOURNAL OF PROSTHETIC DENTISTRY
the socioeconomic situation of these patients tends to be
at the lower end of the scale, and the negative attitude of
dentists themselves, affected by myths and prejudices
about the disease, may lead to inadequate dental care.10
An epidemiologic study was recently conducted,
comparing the overall dental status of patients with ep-
ilepsy with an age-matched nonepileptic control group
of the general population.11 Patients with epilepsy
were shown to have a significantly worse dental status
in many respects, supporting the notion that epilepsy
has a negative effect on dental status.11 However, it is
important to consider that patients with epilepsy com-
prise a heterogeneous group of patients, with varying
types of seizure, seizure frequency, and mental status.
Therefore, a dental classification of patients with epi-
lepsy was created.11 Patients were grouped according
to dental risk factors and dental (prosthodontic) man-
ageability. This dental classification of epilepsy is sum-
marized in Table I. However, the prosthodontic status
of the patients in this study was not analyzed.
The purpose of the present study was to obtain infor-
mation on the level of prosthodontic care of epileptic pa-
tients and the effects of the disease on prosthodontic
treatment. It was hypothesized that as with other aspects
of dental health,11 prosthodontic status of epileptic pa-
tients will also lag behind the general population.
Furthermore, it was expected that seizure-related inju-
ries affect prostheses the same as healthy or restored
teeth. The results of the survey were used in establishing
guidelines for the prosthodontic care of patients with
epilepsy.
MATERIAL AND METHODS
Parts of the study, excluding those pertaining to the
examination of prosthodontic status, have been de-
scribed in detail previously.11 The study was performed
as a collaboration between the Department of Prosthetic
Dentistry, Faculty of Dentistry, and the Department of
Neurology, Faculty of Medicine, of the Semmelweis
University in Budapest. One hundred one epileptic pa-
tients in the regular care of the epilepsy outpatient clinic
of the Department of Neurology were entered into the
study. Patients were nonselected, meaning that all pa-
tients presenting at the clinic during the study period
(September 2001 to June 2002) were included. Only
those with a severe mental handicap were excluded.
These patients would have been unable to cooperate
by keeping still and keeping the mouth open during
a dental examination. One hundred one age-matched
nonepileptic control subjects of the general population
were recruited at a community radiographic chest-
screening clinic. There were no exclusion criteria other
than the disease of epilepsy. All patients and control sub-
jects provided informed consent, and the study was ap-
proved by the local ethics committee.
178
KAROLYHAZY ET AL
Data were collected by the same 2 investigators
throughout the study, the patients’ neurologist and
dentist. Information concerning the disease of epilepsy
itself, past medical history, frequency of visits to the den-
tist, frequency of tooth brushing, seizure-related inju-
ries to teeth and dental prostheses, previous
prosthodontic treatment, and the age of the prosthesis
(the time since it was made) was gathered and recorded
on a standardized questionnaire by the neurologist and
the dentist by reviewing the records of the patient and
questioning the patient.
Patients were then assigned to the appropriate ‘‘den-
tal’’ group (Table I). Group I included patients who had
been seizure free for years, either with or without medi-
cation, patients with rare seizures (less than once a year),
and patients exclusively with seizures that did not involve
the masticatory apparatus (absence, myoclonus, and cer-
tain partial seizures). Group II included patients with
frequent partial seizures involving the masticatory appa-
ratus, accompanied by the twitching of facial and masti-
catory muscles or oral automatisms, such as the grinding
of teeth, but with none or rare (less than once a year)
generalized tonic-clonic seizures. Group III included
patients with frequent (more than once a year) general-
ized tonic-clonic seizures or other seizures associated
with a fall. A dental examination was then performed un-
der standard conditions in a dental chair with adequate
light, using standard dental instruments. The distribu-
tion of epileptic patients in the ‘‘dental’’ subgroups
was the following: 67.3% (68) were in Group I, 7% (7)
in Group II, and 26% (26) in Group III.
The ratio of missing and artificial teeth was deter-
mined and expressed as the prosthetic index.11 Dental
prostheses were examined in detail, and the characteris-
tics were recorded in numeric form on a standardized
sheet, that is, numbers (codes) were assigned to the pos-
sible answers of all questions and characteristics.
Fixed prostheses were first assessed. The age of the
prosthesis and the number of times the prosthesis was
replaced (owing to damage or other causes) was re-
corded. Furthermore, the material of the prosthesis (1,
acrylic, 2, stainless steel; 3, nickel-chrome alloy; 4, sil-
ver-palladium alloy; 5, gold alloy; 6, metal-ceramic; or
7, combination; determined by visual assessment), de-
gree of abrasion or attrition of artificial teeth (1, no signs
of abrasion on occlusal surface(s); intercuspation possi-
ble; 2, superficial abrasion, only few wear facets seen;
or 3, deep abrasion, involving all artificial teeth, inter-
cuspation not possible), state of oral mucosa in the vicin-
ity of the prosthesis (1, normal; 2, signs of inflammation;
or 3, gingival hydantoin hypertrophy), and previous sei-
zure-related injuries of the prostheses were recorded.
Removable partial dentures (RPD) were analyzed
separately for the mandibular and the maxillary arch.
The age of the prosthesis, the number of times the pros-
thesis was replaced (owing to damage or other causes),
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KAROLYHAZY ET AL
Table I. Classification of patients with epilepsy according to dental risk factors and dental manageability and
recommendations for prosthodontic treatment
Criteria of entrance
Group I Patients who have been seizure free
(n = 68) for years, either with or without medication
Patients with rare seizures (less than once a year)
Patients exclusively with seizures that do not involve
the masticatory apparatus (absence, myoclonus,
and certain partial seizures)
Group II Patients with frequent partial seizures involving the
(n = 7) masticatory apparatus, accompanied by twitching of
facial and masticatory muscles or oral automatisms
such as grinding of teeth. Generalized tonic-clonic
seizures, if present, appear less often than once a year.
Group III Patients with frequent generalized tonic-clonic seizures,
(n = 26) more than once a year, or other seizures associated
with a fall
and the amount of time the prosthesis was worn (wheth-
er it was worn daily) was recorded. The type of denture
base material (1, acrylic; or 2, metal or metal-reinforced)
and protection of the marginal gingiva (whether the den-
ture foundation area included the marginal gingiva)
were recorded. Furthermore, means of retention (1,
wrought wire clasp; 2, cast suprabulge clasp; 3, combina-
tion of these clasps; 4, precision attachment; 5, infra-
bulge direct retainer; 6, telescoping crown; or 7,
combination of these), degree of abrasion or attrition
of artificial teeth (as described for fixed prostheses), state
of oral mucosa under and around the RPD (as described
for fixed prostheses), and previous seizure-related inju-
ries were noted.
Complete dentures were examined separately for the
maxillary and mandibular dental arch. The age of the
denture, the amount of time the prosthesis was worn,
the age of becoming edentulous, and the number of
times the denture was replaced was recorded.
Furthermore, any repairs in the denture, base material
(1, acrylic; or 2, metal or metal-reinforced), and previ-
ous seizure-related injuries were noted.
Statistical comparison of the patient and control
groups was performed using the 2-tailed t-test for con-
tinuous variables and the chi-squared test or Fisher’s ex-
act test for categorical variables (a=.05), using statistical
software (SAS 8.2 for Windows; SAS Institute, Cary, NC).
RESULTS
The results are summarized in Table II. It was noted
that the number of missing teeth was significantly higher
FEBRUARY 2005
THE JOURNAL OF PROSTHETIC DENTISTRY
Guidelines for prosthodontic treatment
No special considerations
See Group III
Incisal restoration is discouraged
Fixed rather than removable prostheses are preferred
Fixed partial dentures may include additional abutments
Removable partial dentures should be securely retained
For nearly edentulous subjects, telescopic retention may be
advised with denture bases made of metal or reinforced with
metal
For complete dentures, metal base recommended
(P=.021) but the prosthetic index was significantly
lower in the epileptic group in comparison to the control
group (P,.01), showing an increased risk for losing
teeth and inadequate prosthodontic treatment in pa-
tients with epilepsy. The majority of dental prostheses
were fixed in both groups, which might be related to
the young average age of patients and control subjects.
In the epilepsy group, there were 17 single crowns and
44 fixed partial dentures, 14 with splinting. In the con-
trol group, there were 34 single crowns and 58 fixed par-
tial dentures, 26 with splinting. The average age of the
prostheses was significantly lower in the epilepsy group.
Concerning the material of the fixed prostheses, metal-
ceramic and nickel-chrome with acrylic coverage were
the most common. Significantly fewer epileptic patients
had metal-ceramic prostheses. Other materials were rep-
resented in single patients only. Hydantoin hypertrophy
was not encountered, as only 1 patient was on phenytoin
therapy. Superficial abrasion was found in 39.3% and
deep abrasion in 8.2% of fixed prostheses in the epilepsy
group. The respective figures for the control group were
38% and 5.4%; no difference was found.
Six epileptic patients wore 9 RPDs. In the control
group, 7 subjects wore 13 RPDs. The base material
was more often acrylic than metal in the control group;
however, the difference was not significant. Eight pa-
tients had a complete denture in 12 dental arches, but
2 patients did not wear any denture. In the control
group, 3 subjects had a complete denture in 5 dental
arches. The average age of these epileptic patients at
the time of becoming edentulous was considerably
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THE JOURNAL OF PROSTHETIC DENTISTRY KAROLYHAZY ET AL

Table II. Summary of results

Characteristic Epilepsy Control Statistical difference (a=.05)

Age (years) 37.3 6 14.9 37.9 6 15.2 t test, P=.8

Number of missing teeth* 9.46 6 9.38 6.63 6 7.89 t test, P=.021
Prosthetic index*y 0.396 6 0.44 0.578 6 0.45 t test, P,.01
Fixed prostheses
Total number 61 (in 29 patients) 92 (in 37 patients)
Age of prosthesis (years) 5.25 6 5.26 8.43 6 6.4 t test, P=.0016
Number of replacements 1.62 6 1.29 1.46 6 0.84 t test, P=.34
Material (% of fixed prostheses)
Metal-ceramic 34.4% 52.2% Fisher test, P=.033
Nickel-chrome with acrylic coverage 54.1% 26%
Inflammation of oral mucosa (% of fixed 63.3% 47.8% chi-square, P=.06
prostheses)
Abrasion—superficial and deep (% of fixed 47.5% 43.4% chi-square, P=.62
prostheses)
Seizure-related injuries (number of epileptic 9
patients)
Removable partial dentures
Total number 9 (in 6 patients) 13 (in 7 patients)
Age of prosthesis (years) 4.78 6 4.89 3.85 6 3.18 t test, P=.59
Number of replacements 1.44 6 0.5 1.92 6 1.04 t test, P=.22
Base material Acrylic: 5 Acrylic: 10 Fisher test, P=.33
Metal: 4 Metal: 3
Protection of marginal gingiva 6 out of 9 2 out of 13 Fisher test, P=.02
Means of retention Wrought wire clasps Wrought wire clasps,
cast suprabulge,
and infrabulge
direct retainers
Abrasion—superficial and deep (% of RPD) 66.7% 76.9% Fisher test, P=.66
Inflammation of oral mucosa (% of RPD) 33.3% 53.8% Fisher test, P=.41
Seizure-related injuries (number of epileptic 1
patients)
Complete dentures
Total number 12 (in 8 patients) 5 (in 3 patients)
Age of becoming edentulous (years) 48.2 56.7
Age of prosthesis (years) 4.68 6 4.38 11 6 4.18 t test, P=.019
No. of replacements 1.6 6 0.84 1.6 6 0.54 t test, P=1.0
Base material Acrylic in all Acrylic in all
Seizure-related injuries (number of epileptic 1
patients)
Group averages and standard deviations are given where appropriate. Results are significant for P,.05.
*These data have been previously published.11
y
Ratio of missing and replaced teeth; the number is 1 when all teeth are replaced, 0 when none are replaced.

younger than that of the control subjects, yet at the same
time the average age of the denture was significantly
shorter in comparison to the control group. All patients
who reported seizure-related injuries to the prostheses
were from Group III.
DISCUSSION
The analysis of the prosthodontic status of patients
with epilepsy in comparison to an age-matched control
group indicates that epileptic patients have a significantly
increased risk for losing teeth. The tendency of epileptic
patients becoming edentulous earlier than control sub-
jects was also demonstrated. Furthermore, prosthodon-
tic treatment was not optimal, as significantly fewer
missing teeth were replaced in comparison to a nonepi-
leptic control group of the general population, and the
age of fixed prostheses and complete dentures is lower,
in spite of having more missing teeth. Epileptic patients
also had significantly more nickel-chrome than metal-
ceramic fixed prostheses in comparison to the control
group, which may be esthetically less acceptable. The

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KAROLYHAZY ET AL
reasons for these differences are probably related to fac-
tors such as the socioeconomic situation of the patient
and, consequently, the lack of preventive, restorative,
and prosthodontic dental care.10,11
Seizure-related injuries were reported with all types of
prostheses. However, it is important to note that all sei-
zure-related injuries occurred with patients from Group
III and were associated with generalized tonic-clonic
seizures. This must be considered when designing dental
prostheses. Sanders et al4 emphasized that because of the
danger of seizure-related injuries and aspiration, fixed
prostheses are preferred over removable partial dentures.
If a removable denture is unavoidable, then a metal base
is best used to minimize the chances of fracture.
Moreover, Friedlander and Cummings5 mentioned
that in patients with epilepsy replacement of missing
teeth is important to prevent the tongue from being
caught in the edentulous spaces during seizures.
However, previous studies4,5,10 on prosthodontic care
of epileptic patients have not considered that epilepsy
is a heterogeneous disease with respect to severity and
type.2 Not all patients fall into the same category.
When classified using a dental classification system11
(Table I), patients with a high risk of injury and greatly
increased forces on the teeth and prostheses (Group
III with frequent generalized convulsive seizures) were
classified separately from those who rarely or never
have seizures or only have seizures that have no or minor
effects on the teeth (Group I). Such patients have natu-
rally different needs, and it was demonstrated in the pres-
ent study that only patients classified as Group III are at
an increased risk for seizure-related injuries to prostheses.
Considering this, the authors propose the following
guidelines for prosthodontic treatment of epileptic pa-
tients. Patients in Group I, those that are seizure free
or have only seizures without motor phenomena or falls,
should receive prosthodontic care that is identical with
that of the general population; approximately 70% of ep-
ileptic patients evaluated in this study fall into this cate-
gory. Patients in Group II have seizures with motor
phenomena involving the masticatory apparatus, but
do not have frequent generalized tonic-clonic seizures
or seizures with falls. As a limitation of this study, the
small number of patients in Group II makes it difficult
to judge whether patients who have mainly seizures
with oral automatisms actually have an increased risk
for injury or wear to teeth and prostheses. However, the-
oretically, only slightly increased forces on the teeth and
dental prostheses are expected in this group, as there are
no falls and forceful facial contractions. The guidelines
for prosthetic care may be similar to those described
for Group III, but strict adherence to the guidelines
may not be indicated.
Group III comprises those patients who have fre-
quent generalized tonic-clonic seizures or astatic sei-
zures either because the patients are not responding to
FEBRUARY 2005
THE JOURNAL OF PROSTHETIC DENTISTRY
therapy or compliance is not optimal; approximately
30%-35% of the patients in this study were assigned
into this group. The danger of injury to the teeth and
prostheses during this type of seizure is the highest
and should be considered when designing dental pros-
theses. For occlusal restorations, the use of ceramic in-
lays is best avoided; complete metal-ceramic crowns
are recommended instead. Generally, fixed rather than
removable prostheses are preferred. For fixed partial
dentures, the use of additional abutments may be advis-
able for more stability. If removable partial dentures are
unavoidable, the dentures should be designed with
a large metal base. As more teeth are lost, telescopic re-
tention may be advised with a base made of metal or re-
inforced with metal. The base of complete dentures
should also be metal or reinforced with metal, because
an acrylic base may fracture, increasing the risk of aspira-
tion or dislodgement into the esophagus.6 In the present
study, such a severe complication was not encountered,
because only a few patients wore complete dentures.
A small number of patients with epilepsy, primarily
those where the disease is associated with inborn or peri-
natal encephalopathy,2 have a severe mental handicap
that precludes cooperation. In these patients, general
anesthesia is usually necessary to perform dental treat-
ment, and prosthodontic rehabilitation is usually not
performed. However, these patients were not examined
in this study.
CONCLUSIONS
Patients with epilepsy have an increased risk for loos-
ing teeth, and the prosthodontic status of epilepsy pa-
tients is not optimal as compared with nonepileptic
individuals. This may unfavorably affect quality of life.
Seizure-related injuries to prostheses are also an issue,
but only for those who are refractory to treatment and
suffer from frequent generalized tonic-clonic seizures.
Therefore, the large majority of patients can and should
receive prosthodontic treatment without restrictions. In
a smaller portion of patients, however, certain restric-
tions apply to prevent potentially dangerous seizure-re-
lated complications.
The authors thank Dr Eszter Kovacs for her valuable help in
conducting the survey.
REFERENCES
1. Hauser WA, Annegers JF. Epidemiology of epilepsy. In: Laidlaw J,
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mann; 1999. p.1-2.
3. Buck D, Baker GA, Jacoby A, Smith DF, Chadwick DW. Patients’ experi-
ences of injury as a result of epilepsy. Epilepsia 1997;38:439-44.
4. Sanders BJ, Wedell JA, Dodge NN. Managing patients who have seizure
disorders: dental and medical issues. J Am Dent Assoc 1995;126:1641-7.
5. Friedlander AH, Cummings JL. Temporal lobe epilepsy: its association
with psychiatric impairment and appropriate dental management. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1989;68:288-92.
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6. Abdullah BJ, Teong LK, Mahadevan J, Jalaludin A. Dental prosthesis in- Reprint requests to:
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yngol 1998;27:190-4. DEPT. OF NEUROLOGY, FACULTY OF MEDICINE
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Prosthetic aspects and patient satisfaction with two-implant-retained

Noteworthy Abstracts mandibular overdentures: A 10-year randomized clinical study
of the Naert I, Alsaadi G, Quirynen M. Int J Prosthodont 2004;17:401-10.
Current Literature

Purpose. This study aimed to compare the prosthetic aspects and patient satisfaction with prosthetic care in
two-implant-retained mandibular overdentures, whether implants were splinted with a bar or left with magnets
or ball attachments.
Materials and Methods. Thirty-six completely edentulous patients had two Brånemark implants placed in the
mandibular canine area. A randomized procedure allocated patients into three groups of equal size, each with
a different attachment system: bars, magnets, or balls. Prosthesis retention and mechanical as well as soft tissue
complications were recorded in addition to patient satisfaction. A linear mixed model was fitted with attach-
ment type and time as classification variables and adjusted by Turkey’s multiple range test.
Results. Ball-retained overdentures showed at year 10 the greatest vertical retention force (1,327 g), followed
by bars (1,067 g) and magnets (219 g). In the ball group, need for tightening of abutment screws was the most
common mechanical complication; in the magnet and bar groups, respectively, the most common complica-
tions were wear and corrosion, and the need for clip activation. Prosthesis stability and chewing comfort for
the overdenture were rated significantly lower for the magnet group compared to the ball and bar groups.
Prosthesis stability of the maxillary denture was rated significantly lower in the bar group compared to ball
and magnet groups.
Conclusion. The ball group scored best in relation to retention of the overdenture, soft tissue complications,
and patient satisfaction at year 10. The bar group scored lower for comfort and stability of the maxillary denture.
Magnets offered patients the least comfort. —Reprinted with permission of Quintessence Publishing.

182 VOLUME 93 NUMBER 2