Disease/Medical Condition
EPILEPSY Date of Publication: August 7, 2014
(also known as “seizure disorder”)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated? No
Is medical consult advised? ...... No (assuming patient/client is already under medical care for epilepsy, which is well controlled)
Is the initiation of invasive dental hygiene procedures contra-indicated?** No
Is medical consult advised? ...... Possibly (e.g., if there is medication non-compliance) Is medical clearance required? ...... Possibly (e.g., if there is significant risk of seizure; patient/ client should be seizure-free for several months to be considered controlled) Is antibiotic prophylaxis required? ...... No Is postponing treatment advised? ...... No (assuming patient/client is already under medical care for epilepsy, which is well controlled and for which there are no anticipated exacerbating factors in the office setting)
Oral management implications
Important considerations in the management of epileptic patients/clients are prevention of seizures in the dental chair and preparation for managing seizures if they occur. When a patient/client responds positively to questions about seizures/ epilepsy during health history taking, further information should be obtained. Based on the patient/client’s responses, the dental hygienist may choose to postpone treatment to avoid triggering a seizure in the dental chair. It is valuable for the dental hygienist to know what factors have the potential to exacerbate epileptic seizures in a particular patient/client in order that trigger stimuli can be avoided. The dental hygienist can reduce stress and anxiety by explaining procedures before starting. Bright light should be kept out of the patient/client’s eyes, and dark glasses may assist with this. The dental hygienist should check that the patient/client has taken his/her routine medications, has eaten normally, is not excessively tired, and has not been recently ill before starting treatment. Noncompliance with treatment regimen (especially the taking of prescribed antiseizure medications) is a significant problem in the medical management of some epileptic patients/clients. The dental hygienist should be alert to this possibility for each patient/client with epilepsy, to inform the decision to proceed or not proceed with a particular dental hygiene appointment, as well as to inform potential medical referral. Fatigue can trigger seizures, and thus dental hygiene appointments should be considered for early in the day or at other times when seizures are less likely to occur for a specific patient/client. Alcohol can trigger seizures, and thus consumption should be avoided by the patient/client proximate to the dental hygiene appointment. Hormonal changes during an epileptic woman’s reproductive cycle may affect the tendency to have seizures. When administered with at least 20% oxygen, nitrous oxide sedation is generally not contraindicated for patients/clients with epilepsy. However, local anaesthetics (such as lidocaine) may have pro-convulsant effects, particularly if administered in large amounts or if inadvertently injected intravenously.1 Most persons with epilepsy (two out of three) achieve good seizure control with prescribed medication.
1 Local anaesthetics may also have anticonvulsant effects; intravenous lidocaine has been used to treat status epilepticus, mainly in children.
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Disease/Medical Condition
EPILEPSY
(also known as “seizure disorder”)
Oral management implications (cont’d)
Despite preventive measures, seizures may still occur in the dental hygiene office. Management should focus on preventing injury and maintaining adequate ventilation.
◊ Management of generalized tonic-clonic (grand mal) seizures is as follows:
1. Recognize prodrome or aura.
2. Terminate procedure — remove instruments and dental appliances from patient/client’s mouth.
3. Activate office emergency team. 4. Position the patient/client in supine position with legs elevated; lower dental chair and protect patient/client from injury. Turn patient/client to side to minimize aspiration of secretions; do not place anything in the mouth or between teeth.
5. Time the seizure. 6. Consider activation of emergency medical services — Call 911 if the seizure lasts longer than 3 to 5 minutes or the patient/client becomes cyanotic from the onset. 7. Assess and perform basic life support as needed (circulation airway breathing).
8. After seizure, reassure patient/client and allow him/her to recover; assess O saturation and administer oxygen as 2 needed; monitor vital signs; briefly assess oral cavity for injury to teeth and tissues.
9. Discharge patient/client to hospital, physician, or home with a responsible adult, depending on post-seizure circumstances.
The ongoing medical management of epilepsy is usually based on long-term drug treatment. Phenytoin, carbamazepine, and valproic acid are first-line agents commonly used in the ongoing management of tonic-clonic seizures, whereas drugs of choice for absence seizures included ethosuximide, valproic acid, lamotrigine, and clonazepam. These, and other, antiepileptic drugs (AEDs) may have adverse effects with dental hygiene treatment considerations. For patients/clients being treated with the phenytoin, the frequency of continuing care appointments should take into account the presence and severity of drug-induced gingival enlargement. Drowsiness is a side effect of some AEDs, particularly phenobarbital. Some drugs prescribed by dentists or physicians can interfere with seizure control because they interact with antiepileptic medications. For example, metronidazole, antifungal agents (e.g., fluconazole) and antibiotics (e.g., erythromycin and clarithromycin) may alter the metabolism of certain antiepileptic drugs. Powered toothbrushes may be too stimulating for some patients/clients and should be recommended only after determining if they can be tolerated. Co-morbid conditions are common in patients/clients with epilepsy, and the dental hygienist should be alert for them.
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Disease/Medical Condition
EPILEPSY
(also known as “seizure disorder”)
Oral manifestations
While epilepsy and seizures themselves do not produce oral changes, accidents resulting from seizures and medications used to treat the condition may result in oral sequelae. Scarring of the lips, buccal mucosa, and the tongue may indicate past injury to the oral cavity due to biting during a seizure. Teeth may be fractured due to forceful biting that often accompanies tonic-clonic seizures. Enzyme-inducing drugs, antiepileptic drugs (e.g., phenytoin, phenobarbital, and carbamazepine) alter the metabolism and clearance of Vitamin D and thus contribute to increased fracture risk via osteopenia and osteomalacia. TMJ dislocation can result from seizure-related trauma. The most common significant oral complication seen in epileptic patients/clients is gingival hyperplasia, which is associated with the antiepileptic medications phenytoin, phenobarbital, and, more rarely, valproic acid and vigabatrin. Phenytoin alters the metabolism of gingival fibroblasts, resulting in the production of excessive amounts of collagen. Drug-induced gingival hyperplasia occurs in about half of patients/clients on continual phenytoin therapy within 12—24 months of initiation, and it may be disfiguring as well as interfere with mastication and speech. Ulcerations and glossitis may result from vitamin B-12 or folate deficiency caused by various anti-epileptic drugs. Adverse effects of phenytoin, in addition to gingival hyperplasia, include aphthous ulcers, delayed healing, increased incidence of microbial infection, gingival bleeding, and osteoporosis. More rarely, phenytoin (and some other AEDs, particularly carbamazepine) may trigger Stevens-Johnson syndrome, a serious condition that involves sloughing of the skin and mucous membranes. Xerostomia, stomatitis, and intra-oral petechiae or bleeding (resulting from drug-induced thrombocytopenia) are infrequent adverse effects of carbamazepine. Rash that may involve the oral cavity has been associated with lamotrigine. Valproic acid can cause bone marrow suppression and decrease platelet count, which may occasionally lead to clinically significant bleeding and impair wound healing. Valproic acid can also cause direct bone marrow suppression, which can impair wound healing and increase post-operative bleeding and infections.
Related signs and symptoms
Epilepsy is a general term for conditions characterized by recurrent seizures. There are many kinds of seizures (i.e., paroxysmal changes in central neurologic function), but all involve abnormal electrical activity in the brain that causes discrete episodes of involuntary changes in body movement (e.g., convulsions) or in sensation, awareness, or behaviour. While seizures are required for the diagnosis of epilepsy, not all seizures imply the presence of epilepsy. Seizures do not necessarily indicate epilepsy if they only occur as a result of a temporary medical condition such as a high fever, hypoglycemia, alcohol or drug withdrawal, or immediately following a brain concussion. Although classification of seizures has evolved over time, a former classification system2 separated seizures into focal (also known as partial) and generalized types depending on the extent of brain involvement. Focal seizures are the most common type experienced by persons with epilepsy; they occur when abnormal electrical activity affects only one area of the brain.3 Generalized seizures involve both sides of the brain, and they cause alteration or loss of consciousness either briefly or for a longer period of time. While there are many types of seizures, three of the common generalized ones most relevant for dental hygienists are: tonic- clonic (convulsive or “grand mal”) seizures; absence (“petit mal”) seizures; and convulsive status epilepticus.
2 International League Against Epilepsy (ILAE) 3 Focal seizures may be further classified as simple (in which the person remain conscious) and and complex (in which consciousness is altered or lost).
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Disease/Medical Condition
EPILEPSY
(also known as “seizure disorder”)
Related signs and symptoms (cont’d)
Tonic-clonic seizures have a typically rapid onset but may be preceded by a prolonged prodrome (premonition) or, less commonly, a momentary aura. Associated with tonic and clonic phases of muscular spasm, the patient/client loses consciousness. Defecation and micturition may occur. Cyanosis may be observed during the tonic phase (continuous tension or contraction) lasting for 20—40 seconds. The clonic phase (alternating series of contractions and partial relaxation) may last for several minutes. The patient/client wakes up from the seizure with a severe headache and confusion. Recovery may be quick or the patient/client may be irritable. Most tonic-clonic seizures end within 1 to 2 minutes, but post-ictal signs/ symptoms (i.e., after-effects) may last for much longer. Absence seizures usually appear between 3 years of age and puberty. They consist of a transient loss of consciousness, and episodes typically last less than 30 seconds. Upward rolling of the eyes, drooling, rhythmic nodding of the head, and/or slight quivering of the trunk and limb muscles may be observed. Convulsive status epilepticus is variously defined, including the following: the active part of a tonic-clonic seizure lasts 5 minutes or longer; a person goes into a second convulsive seizure without recovering consciousness from the first one; or, a person has repeated convulsive seizures for 30 minutes or longer.4 This condition is most frequently caused by an abrupt withdrawal of anticonvulsant medication or an abused substance, but it may also be triggered by infection, neoplasm, or trauma. It is a life-threatening medical emergency, which requires urgent medical intervention.5 Epilepsy affects persons of all ages, with a peak incidence of seizures in childhood and old age. The prevalence of epilepsy in Canada approaches 1 per 100 people, with about 360,000 persons affected. Up to 10% of the population will have at least one seizure in a lifetime, and 2% to 4% will experience recurrent seizures at some point. Some children outgrow the disorder, but others will require ongoing medical care. 75% of epilepsy is classified as primary or idiopathic (i.e., no known cause), with the remainder being secondary, due to causes such as birth asphyxia, head injury, or meningitis in children, or cerebrovascular disease or metastatic tumours in older persons. Rash is a common side effect of antiepileptic drugs, occurring in 5% to 7% of patients/clients taking phenytoin and 5% to 17% of patients/clients taking carbamazepine. Coarsening of facial features may occur in patients/clients on long-term phenytoin, which is related to increased osteoblast activity. Osteoporosis and increased fracture risk are associated with long-term use of some antiepileptic drugs (e.g., carbamazepine, phenytoin, primidone, and valproic acid). Epilepsy is generally more severe in persons who have developmental disabilities. Dental hygienists should be alert to potential co-morbid conditions in patients/clients with epilepsy. Persons living with epilepsy — particularly children — often have psychosocial and emotional sequelae of living with a chronic, potentially unpredictable disease. Parents may interfere with their child’s psychosocial adjustment by being overprotective or having low expectations of him/her.
4 The duration of continuous seizure activity used to define status epilepticus has varied over time, with the recent trend being to shorter definitional time. Practically, once seizures have continued for more than a few minutes, treatment should begin without additional delay. 5 Non-convulsive status epilepticus (NCSE) also requires emergency medical treatment in a hospital, particularly given that NCSE predisposes to convulsive status epilepticus. NCSE is a term used to describe long or repeated absence or focal impaired awareness (complex partial) seizures.
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Disease/Medical Condition
EPILEPSY
(also known as “seizure disorder”)
References and sources of more detailed information
College of Dental Hygienists of Ontario http://www.cdho.org/Advisories/CDHO_Advisory_Epilepsy_and_Seizures.pdf Perks A, Cheema S, Mohanraj R, Anaesthesia and epilepsy. British Journal of Anaesthesia 2012;108(4):562—571. https://doi.org/10.1093/bja/aes027 Joshi SR, Pendyala GS, Saraf V, Choudhari S, Mopagar V. A comprehensive oral and dental management of an epileptic and intellectually deteriorated adolescent. Dent Res J (Isfahan). 2013;10(4):562–567. Aragon CE and Burneo JG. Understanding the Patient with Epilepsy and Seizures in the Dental Practice. J Can Dent Assoc 2007;73(1):71-76. http://www.cda-adc.ca/jcda/vol-73/issue-1/71.pdf Public Health Agency of Canada, Government of Canada https://www.canada.ca/en/public-health/services/publications/diseases-conditions/epilepsy.html Epilepsy Ontario http://epilepsyontario.org/ Epilepsy Canada https://www.epilepsy.ca Epilepsy Foundation https://www.epilepsy.com https://www.epilepsy.com/learn/challenges-epilepsy/seizure-emergencies/status-epilepticus https://www.epilepsy.com/article/2016/12/2017-revised-classification-seizures https://www.epilepsy.com/article/2014/10/auras-generalized-epilepsy Epilepsy Society https://www.epilepsysociety.org.uk/should-you-worry-about-osteoporosis#.Xg4qRRdKiu4 Centers for Disease Control and Prevention http://www.cdc.gov/Epilepsy/ University of Washington School of Dentistry https://dental.washington.edu/wp-content/media/sp_need_pdfs/Epilepsy-Adult.pdf http://dental.washington.edu/wp-content/media/sp_need_pdfs/Epilepsy-Dental.pdf Uptodate https://www.uptodate.com/contents/convulsive-status-epilepticus-in-adults-classification-clinical-features-and-diagnosis? search=convulsive-status-epilepticus-in-adults-classification-features-and- diagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Gurbuz T (October 12th 2011). Epilepsy and Oral Health, Chapter 9 in Novel Aspects on Epilepsy, Foyaca-Sibat H (ed.), IntechOpen, DOI: 10.5772/19265. http://www.intechopen.com/books/novel-aspects-on-epilepsy/epilepsy-and-oral-health Ibsen OAC and Phelan JA. Oral Pathology For The Dental Hygienist (6th edition). St. Louis: Saunders Elsevier; 2014. Malamed SF. Medical Emergencies in the Dental Office. St. Louis: Elsevier Mosby; 2015. Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier Saunders; 2020. Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8th edition). St. Louis: Elsevier Mosby; 2013.
Malamed SF. Medical Emergencies in the Dental Office (7th edition). St. Louis: Elsevier Mosby; 2015.
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Disease/Medical Condition
EPILEPSY
(also known as “seizure disorder”)
References and sources of more detailed information (cont’d)
Pickett FA and Gurenlian JR. Preventing Medical Emergencies: Use of the Medical History in Dental Practice (3rd edition). Baltimore/Philadelphia: Wolters Kluwer Health; 2015. ◊ Management of generalized tonic-clonic (grand mal) seizures adapted from: Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier Saunders; 2020; citing adaptation from Malamed SF. Medical Emergencies in the Dental Office (7th edition). St. Louis: Elsevier Mosby; 2015 + adapted from Aragon CE and Burneo JG. Understanding the Patient with Epilepsy and Seizures in the Dental Practice. J Can Dent Assoc 2007;73:1 at http://www.cda-adc.ca/jcda/vol-73/issue-1/71.html and Pickett FA and Gurenlian JR. Preventing Medical Emergencies: Use of the Medical History in Dental Practice (3rd edition). Baltimore/Philadelphia: Wolters Kluwer Health; 2015.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.
Date: July 10, 2014 Revised: January 2, 2020
www.cdho.org 6