Ministry of higher education

And scientific research

Babylon University
Faculty of Dentistry

(DENTAL MANAGEMENT OF
EPILEPTIC PATIENT)

Done By
Fourth Stage– ‫عباس هيثم بهلول‬
Supervised by
Lecturer Dr .Ali Mohsin

September 2020 A.D. 1442 A.H.

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 INTRODUCTION
The term epilepsy includes disorders or
syndromes with widely variable pathophysiologic
findings, clinical manifestations, treatments, and
outcomes. Epilepsy is not a specific diagnosis but
rather a term that refers to a group of disorders
characterized by chronic and recurrent,
paroxysmal changes in neurologic function
(seizures), altered consciousness, or involuntary movements caused by abnormal and
spontaneous electrical activity in the brain. Seizures may be convulsive (i.e.,
accompanied by motor manifestations) or may occur with other changes in
neurologic function (i.e., sensory, cognitive, and emotional). Seizures are
characterized by discrete episodes, which tend to be recurrent and often are
unprovoked, in which movement, sensation, behavior, perception, and consciousness
are disturbed. Symptoms are produced by excessive temporary neuronal discharging,
which may result from intracranial or extracranial causes. Although seizures are
required for the diagnosis of epilepsy, not all seizures imply presence of epilepsy.
Seizures may occur during many medical or neurologic illnesses, including stress,
sleep deprivation, fever, alcohol or drug withdrawal, and syncope. A list of epilepsy
syndromes and the currently accepted classification of seizure types.

THIS SEIZURE CLASSIFICATION

based on clinical behaviors and electroencephalographic changes, consists of two
major groups: partial and generalized.
1- Partial seizures are limited in scope (to a part of the cerebral hemisphere) and clinical
manifestations and involve motor, sensory, autonomic, or psychic abnormalities.
Partial seizures are subdivided into simple, in which consciousness is preserved, and
complex, in which consciousness is impaired.

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2- Generalized seizures are more global in scope and manifestations. They begin
diffusely, involve both cerebral hemispheres, are associated with alteration in
consciousness, and frequently produce abnormal motor activity.3 Discussion in this
section is limited to generalized tonicclonic seizures (idiopathic grand mal), because
these represent the most severe expression of epilepsy that the dentist is likely to
encounter.

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).

SIGNS AND SYMPTOMS

The clinical manifestations of generalized tonic-clonic convulsions (grand mal
seizures) are classic. An aura (a momentary sensory alteration that produces an
unusual smell or visual disturbance) precedes the convulsion in one third of patients.
Irritability is another premonitory signal. After the aura warning, the patient emits a
sudden “epileptic cry” (caused by spasm of the diaphragmatic muscles) and

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 immediately loses consciousness. The tonic phase consists of generalized muscle
rigidity, pupil dilation, rolling of the eyes upward or to the side, and loss of
consciousness. Breathing may stop because of spasm of respiratory muscles. This
phase is followed by clonic activity consisting of uncoordinated beating movements
of the limbs and head, forcible jaw closing, and up and down head rocking. Urinary
incontinence is common, but fecal incontinence is rare. The seizure (ictus) usually
does not last longer than 90 seconds; thereafter, movement ceases and muscles relax,
with a gradual return to consciousness, accompanied by stupor, headache, confusion,
and mental dulling. Several hours of rest or sleep may be needed for the patient to
regain full cognitive and physical abilities.

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

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DENTAL MANAGEMENT
the patient’s health history is the main prerequisite for successful treatment and can
prevent many complications.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 when the health history is taken. Some epileptic patients
may conceal their disorder for fear of being refused dental treatment or they consider
epilepsy as an embarrassing disease. In this case the information requested on the health
history regarding medications the patient takes should alert the dentist to a possible seizure
disorder. If the patient has a seizure while in the dental chair:
1- the primary task of management is to protect the patient and try to prevent injury.
2- No attempt should be made to move the patient to the floor.
3- the instruments and instrument tray should be cleared from the area.
4- the chair should be placed in a supported supine position .
5- The patient’s airway should be maintained patent.
6- No attempt should be made to restrain or hold the patient down.
7- Passive restraint should be used only to prevent injury that may result when the patient
hits nearby objects or falls out of the chair.
8- If a mouth prop (e.g., a padded tongue blade between
the teeth to prevent tongue biting) is used, it should be
inserted at the beginning of the dental procedure
.Trying to insert a mouth prop is not advised during
the seizure, because doing so may damage the
patient’s teeth or oral soft tissue and may be nearly
impossible.
9- An exception is the case in which the patient senses an
impending seizure and can cooperate.A grand mal
seizure generally does not last longer than a few
minutes. Afterward, the patient may fall into a deep
sleep from which he or she cannot be aroused.

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10 - Oxygen (100%), maintenance of a patent airway, and mouth suction should be
provided during this phase.
11 -Alternatively, the patient can be turned to the side to control the airway and to
minimize aspiration of secretions.
Within a few minutes, the patient gradually regains consciousness but may be confused,
disoriented, and embarrassed. Headache is a prominent feature during this period. If the
patient does not respond within a few minutes, the seizure may be associated with low
serum glucose, and delivery of glucose may be needed. No further dental treatment should
be attempted after a generalized tonic-clonic seizure, although examination for sustained
injuries (e.g., lacerations, fractures) should be performed. In the event of avulsed or
fractured teeth or a fractured appliance, an attempt should be made to locate the tooth or
fragments to rule out aspiration. A chest radiograph may be required to locate a missing
fragment or tooth.
In the event that a seizure becomes prolonged (status epilepticus) or is repeated,
intravenous lorazepam (0.05 to 0.1 mg/kg) 4 to 8 mg, or 10 mg diazepam, generally is
effective in controlling it. Lorazepam is preferred by many experts because it is more
efficacious and lasts longer than diazepam.2,3 Oxygen and respiratory support should be
provided, because respiratory function may become depressed. If the seizure lasts longer
than 15 minutes, the following protocol should be implemented: secure intravenous
access, repeat lorazepam dosing, administer fosphenytoin, and activate the emergency
medical services (EMS) system

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,

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 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.

CONCLUSION
As a result of poor oral hygiene, dental trauma during seizures and the side effects of
the medication for the epileptic patients; tooth loss, caries and periodontal disease
found more frequently in epilepsy sufferers than in non-sufferers. For that reason, the
epileptic patients need more dental treatment then other patients. However, it is a fact
that special treatment is not required for patients who have not suffered from a
seizure for a long period of time or for patients who do not experience involuntary
masticatory strokes during seizure. Consequently, after a detailed anamnesis and
examination, most epileptic patients can receive a better dental management than that
they can usually have.

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 REFERENCES
1. Little_and_Falace’s_Dental_Management chapter 27 Neurologic
Disorders page 499
2. Turner MD, Glickman RS. Epilepsy in the oral and maxillofacial
patient: current therapy. J Oral Maxillofac Surg 2005; 63:996-
1005.
3. Devinsky O. Epilpsy patient and family guide, 2nd ed.
Philadelphia: Davis Company, 2002. p. 26-49.
4. Annegers JF. The epidemiology of epilepsy. The treatment of
epilepsy: Principles and Practice, 2nd
5. Greenwood M, Meechan JG. General medicine and surgery for
dental practitioners. Part 4:Neurological disorders.