Presented By:

Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

Chapter 63
The patient with a seizure disorder
What is a seizure?
 A sudden uncontrolled electrical discharge of neurons in the brain.
o Causes changes in behavior, movements or feelings, and can involve loss
of consciousness
o Awareness with or without convulsive movements or spasms
o They are unprovoked, unpredictable and involuntary
o Length of a seizure is uncontrollable
o They range in severity which vary by where and how they begin in the
brain
o Most seizures last from 30 seconds to two minutes
o A seizure that last longer than five minutes is a medical emergency
 Other terms for seizure: convulsion, fit, spell and ictus
Seizures can lead to dangerous situations for you and others including:
fallings, drowning, car accidents, pregnancy complications, emotional
health issues
What is epilepsy?
 A term to describe a group of functional disorders of the brain characterized by
recurrent seizures.
 Each year, about 150,000 American’s are diagnosed with CNS disorder that
causes seizures.
 Is the fourth most common neurological disease
 Estimated that about 1.2 percent of U.S. people have active epilepsy
 Most commonly diagnosed before age 20 or after age 65
Seizures are a symptom of epilepsy, not every person who has a seizure has epilepsy.
Classification:
Diagnosis from a seizure is made from:
 Clinical signs and symptoms-
o Confusion that can last for a few minutes to hours.
o Consciousness is impaired to varying degrees.
o May manifest purposeless movements or actions followed by confusion,
incoherent speech, ill humor, unpleasant temper, does not remember what
happened during the attack
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

 History
 Electroencephalography
 Functional neuroimaging
 The syndromes have been classified by the following:
o Age-related onset
o Symptoms
o Anatomic localization in the brain
Types of seizures:
 Basic types:
o Generalized-more than 30% experience this type
o Focal
o Unknown origin

Generalized seizures:
 Affects the entire brain
o Tonic-clonic
 Muscles of the chest and pharynx may contract at the same time
 Loss of consciousness is sudden and complete
 Stiffening muscles primarily in the arms, legs and back
 Skin color turns pale to bluish, breathing is shallow or stops briefly
 Possible loss of bladder, and rarely, bowel control
 Incident usually last 1-3 minutes
 Clonic
o Repetitive jerking movements across both sides of the body
o Absence seizure
 Loss of consciousness begins and ends abruptly in about 5-30 seconds
 Most common in children, and might lead to learning difficulties if not
identified
 May become pale
 May have rhythmic twitching of eyelids, eyebrows, head or chewing
movements
 Attack ends as abruptly as it begins
o Myoclonic
 Jerking or twitching movements occur in the arms, legs, or upper body
o Atonic
 Involve a loss of muscle tone and definition, ultimately leading to falls or
an inability to hold the head up
o Focal seizures
 May involve only part of the brain
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

o Unknown seizures
 Include epileptic spasms.
Etiology:
Nerve cells in the brain create, send and receive electrical impulses, any disruption in
these communication pathways can lead to a seizure
 Genetic
o Neurologic abnormalities
 It is still unclear if ethnicity plays a role in who develops epilepsy
 Overall, no gender is more likely to develop epilepsy than the
other. However, its possible each gender is more likely to develop
certain subtypes of epilepsy
 Age: begins at any age
 Structural metabolic
o Neurologic and nonneurologic medical condition
 Congenital condition
 Perinatal injuries
 Brain tumor
 Cerebrovascular disease
 Trauma
 Infection
 Degenerative brain disease
 Metabolic and toxic disorders
 Complication of cancer
 Unknown
o A neurological examination may diagnose the reason
Implications:
 Possibility of severe injury, accidents, or embarrassment, patients can be legally
restricted from participating in certain activities that include:
o Vocation: occupations that involve use of machinery or require physical
activity
o Licenses: certain licenses- ex: driver’s license
o Independent living: due to health risk
Clinical Manifestations:
Symptoms:
 Can range from mild to severe depending on the type of seizrue
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

Aura:
 Some patients will have a warning such as a special sensory stimulus, a sensation
of numbness, tingling, twitching, or stiffness of certain muscles; not all patients
will have a warning or aura
Prevention of seizures:
 Primary prevention involves avoiding brain injury through use of protective
devices ex: helmets
 Secondary prevention involves early detection and compliance with
recommended treatment
 Tertiary prevention involves interventions that decrease precipitating factors
Treatment:
Medications:
 Antiepileptic drug
Choices:
 Patients may be placed on one antiepileptic drug or a combination of several
 Choice of therapy is related to type of seizure disorder
Side effects:
 Each medication affects the patient to varying degrees
 Can include
o Allergic reaction, rash
o Fatigue, drowsiness, weakness, ataxia, headache, slurred speech
o Nausea, vomiting
o Memory loss
o Damage to liver
o Leukopenia: delayed healing and infection
o Osteoporosis
o Increase or unknown risk of birth defects
o Thrombocytopenia
o Hirsutism; hypertrichosis
o Oral change of gingival enlargement most common with phenytoin
o Numerous drug interactions including: other antiepileptic drugs,
acetaminophen, nonsteroidal anti-inflammatory drugs, erythromycins, and
reduction in efficacy of oral contraceptives
 Elderly and children
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

o Both are more sensitive to side effects of weakness, unsteadiness,

cognitive alterations
Precaution: herbal supplements:
 Certain herbal products are used as self-medication to prevent seizures. These
may interfere with prescribed antiepileptic drugs
 Patients are asked to inform their primary care provider and dental team
 Some herbal supplements such as ginkgo biloba, St. John’s wart, and some
essential oils may affect dental treatment.
Surgery:
 Resection of the epileptogenic area in the brain
 If total resection leads to unacceptable deficits, multiple subpial transections are
removed. (series of small parallel slices)
 Gamma-knife radiosurgery involves delivery of a focused dose of radiation to the
epileptogenic area in the brain
 Vagus nerve stimulation utilizes a pacemaker-like device to deliver signals

Oral Findings:
 Epilepsy produces no oral changes
 Specific oral changes relate to
o Side effects of antiepileptic drugs or other therapy
o Oral accidents during a seizure
o Side effects of epilepsy, such as depression leading to poor oral hygiene
Effects of accidents during seizures:
Scares of lips and tongue:
 Tongue, cheek, or lip may be bitten
 Scars may be observed during the extraoral/intraoral examination
Fractured teeth:
 Teeth may be clamped and bruxing may be forceful enough to fracture teeth
 May be sharp and lacerate tissues and need to be smoother or restored
 May extend into the pulp of a tooth, allowing bacterial infection
Gingival overgrowth/gingival hyperplasia:
 Occurs in 25-50% of persons using phenytoin
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

 Other antiepileptic drugs also induce gingival overgrowth less frequently

 Phenytoin may cause fibroblasts and osteoblasts to deposit excessive
extracellular matrix, causing gingival overgrowth
 Meticulous oral hygiene reduces the occurrence and severity of gingival
overgrowth
Occurrence:
 Incidence is greater in younger patients than in older patients just
beginning therapy
 Gingiva may start to enlarge within a few weeks of even after a few years
 The size of the dose and the length of treatment are not necessarily factors
 Anterior gingiva is usually more affected than posterior and maxillary
more than mandibular
 Facial and proximal areas: more affected than lingual and palatal areas
 Although rare, an overgrowth of tissue may occur in an edentulous area
 Overgrowth of tissue surrounding dental implants can occur
Treatment of gingival overgrown:
 Change in drug prescription
o Making the change should be just prior to a surgical removal
procedure
 Nonsurgical treatment
o Scaling
o Fibrotic tissue, cannot be expected to shrink
 Surgical removal
o Gingivectomy
o Periodontal flap
 Differential diagnosis of medications causing gingival enlargement
o Antiseizure medications
o Ethosuximide
o Valproic acid
o Primidone
o Calcium channel blockers
o Immunosuppressant cyclosporin
o Tacrolimus
Dental hygiene care plan
 Patients with a seizure disorder may be under the car of other specialist
including a neurologist, social worker, and a primary care physician
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

Patient history
 Patients with autism may present with social, communication, and/or
behavioral problems, in addition to seizure disturbances
 Patients with well controlled epilepsy may still be at risk to have a seizure
 For seizure-prone patients: advise wearing medical alert jewelry
Information to obtain: review box 63-3 on page 1065
Patient approach:
 Calm, reassuring atmosphere and treat with patience and empathy
 Motivational interviewing approach with patient’s education
 Encourage self-expression
 Recognize possible impairment of memory
 Help the patient develop interest in caring for their mouth
 Drugs used in treatment tend to make the patient drowsy, and chronic
illness sufferers tend to have more frequent health issues that interfere
with appointments.
 Be understanding when the patient is late or misses an appointment
Care plan: instrumentation:
 All patients need to be instructed and motivated to comply with an
effective biofilm control program
 Complete removal of all deposits
Prior to and at the start appointment for patients treated with phenytoin therapy
 A rigorous biofilm control program and complete scaling are introduced
 The patient can be helped to understand that, with controlled oral hygiene
and emphasis on all phases of prevention, gingival overgrowth can be
prevented to a large degree
Initial appointment series for the patient treated with phenytoin
 Slight or mild gingival overgrowth
o Nonsurgical treatment
o Frequent continuing care appointments
 Moderate gingival overgrowth
o Re-evaluation of the tissue
o Optimum level of oral health may be attained by changing their
medication
 Sever fibrotic overgrowth
o Initial scaling and biofilm control
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

o Plans to change the drug or altering the dose

Continuing care intervals
 Frequent appointments on a 1, 2, to 3-month schedule
 Most patients need continuing assistance and supervision
Care plan: prevention
 Daily biofilm removal and fluoride therapy, use of pit and fissure sealants,
and dietary control
 Initiation of preventive measures as soon as possible
Emergency Care
Objectives:
 Prevent body injury and accidents related to the oral structures, such as
o Tongue bite
o Broken or dislocated teeth
o Dislocated or fractured jaw
o Broken fixed or removable dentures
 Ensure adequate ventilation
Differential diagnosis of seizure
 Syncope
 Migraine headache
 Transient ischemic attack
 Cerebrovascular accident, stroke
 Sleep disorder
 Movement disorders such as dyskinesia, common, for example, in patients
with cerebral palsy or multiple sclerosis
 Overdose of local anesthetic
 Hypoglycemia or insulin overdose in a patient with diabetes
 Hyperventilation
Preparation for appointment
 Place emergency materials in a convenient location
 Have patient remove dentures for duration of appointment
 Provide a calm and reassuring atmosphere
 Have other dental personnel available in case of an emergency
Emergency procedure
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

 Make no attempt to stop the convulsion or restrain the patient

 Terminate clinical procedure; call for assistance
 Protect patient for injury
o Position patient: lower chair and tilt to supine; raise feet
o Keep patient from falling out of dental chair
o Push aside sharp objects, movable equipment and instrument trays
o Loosen tight belt, collar, necktie
o Do not place anything between the teeth
o Establish airway; check for breathing obstruction;
o Monitor vital signs
o Stay beside the patient to prevent personal injury and reassure
o Check for level of consciousness and determine if emergency
medical assistance is required
o When seizure is still occurring or has recurred within 5 minutes,
activate emergency medical system
Postictal phase
 Document emergent situation
 Allow patient to rest
 Talk to the patient in a quiet, reassuring tone
 Check oral cavity for trauma to teeth or tissues
 Contact the patient’s family/friend to accompany the patient

Status epilepticus:
 Defined as one or more seizures lasting more than 30 minutes
 Prolonged seizure may not end spontaneously; brain injury can occur and
result in long term morbidity or death
 Seizure lasing more than 5 minutes should be considered to progress to
status epilepticus
 Emergency medical assistance is sought immediately, and the patient is
transported to an emergency department
 Basic life support provided if necessary
Documentation:
Need complete permanent records that show:
 Complete health history, vitals, radiographs, findings of the extra and
intraoral examination, periodontal history, charting, and tissue description
 Progress notes for each appointment
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

 Information about the type of seizure

Question 1: What is a Seizure?
A. Discoloration on the skin that is blue-black with irregularly formed hemorrhagic areas.
Color changes with time yellow or greenish-brown.
B. Loss of sensibility to pain without loss of consciousness.
C. A sudden uncontrolled electrical discharge of neurons in the brain caused by brain cells
moving simultaneously at a faster than normal rate.
D. Perception of two images at a single object; double vision.

Question 2: Gingival overgrowth occurs in 25-50% of people using what medication?

A. Valproic acid
B. Phenytoin
C. Primidone
D. Ethosuximide

Question 3: Seizures are a symptom of epilepsy, not every person who has a seizure has
epilepsy. Epilepsy It is the fourth most common neurological disease.
A. Both statements are true.
B. The first statement is false, but the second statement is true.
C. Both statements are false.
D. The first stamen is false, but the second statement is true.
 Presented By:
Brooke DeRouen,
MacKenzie Locke,
Alyssa Shepard

References:
https://www.mayoclinic.org/diseases-conditions/seizure/symptoms-causes/syc-20365711
https://www.healthline.com/health/epilepsy/facts-statistics-infographic#23
Clinical Practice of the Dental Hygienist / Edition 12 by Esther Wilkins