THE PATIENT

Presented By:
WITH A SEIZURE Brooke DeRouen, MacKenzie Locke,
DISORDER Alyssa Shepard
 WHAT IS A SEIZURE?

• Convulsion, Fit, Spell, Ictus

• A seizure is a sudden uncontrolled electrical discharge of neurons in the brain
caused by brain cells moving simultaneously at a faster than normal rate.
• Seizures can start and spread to different parts of the brain, resulting in
changes of behavior, sensations, movements/feelings, and consciousness.
• Awareness with or without convulsive movements or spasms
• Unprovoked, unpredictable, involuntary
• Range in severity (depends on where and how they began in the brain)
• Length is uncontrollable, but most seizures last 30 seconds to 2 minutes
A SEIZURE THAT LASTS LONGER THAN
5 MINUTES IS A MEDICAL EMERGENCY.

Seizures can lead to dangerous situations for you and

others including: fallings, drowning, car accidents, pregnancy
complications, emotional health issues
 EPILEPSY

• Epilepsy is a term used 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.
• It 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.
 DENTAL PERSONNEL

• How do seizures affect dental treatment?

• Care of the oral cavity is necessary because of its relationship to general
health
• Treatment modalities of epilepsy and seizures may affect the oral tissues as
well as overall dental treatment
• Dental personnel should be aware of the possible issues associated with
seizures and how to evaluate the patient
• Dental personnel should also know how to apply emergency measures in case
of an episode during an oral procedure

{Seizures themselves produce no oral changes, but side effects of antiepileptic

drugs or other therapy can}
 CLASSIFICATION

• Diagnosis is made from:

• Clinical Signs and Symptoms
• Medical History
• Electroencephalography
• Functional neuroimaging

• Syndromes:
• Age-related onset
• Symptoms
• Anatomic location in the brain
 SIGNS AND SYMPTOMS

• Short term memory loss

• Trancelike state
• Unpleasant temper
• Confusion that can last for a few minutes
to hours • Cognitive or emotional distress
• Consciousness is impaired to varying • Fainting
degrees
• Fatigue
• Uncontrolled movements/jerking of arms
• Sensory: pins and needles
and legs
• Ill humor
• Incoherent speech
1. GENERALIZED
2. FOCAL
3. UNKNOWN
 GENERALIZED SEIZURES

• Generalized seizures affect the entire brain, more than 30% experience this type.
• Tonic-Clonic : Muscles of the chest and pharynx may contract at the same time
• Forcing air out making a sound known as “epileptic cry”
• 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
• May bite tongue without realizing it
• Possible loss of bladder, and rarely, bowel control
• Incident usually last 1-3 minutes then respiration returns
• Clonic: Repetitive jerking movements across both sides of the body
• Seizure may continue without recovery and progress to status epilepticus

• 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, patient quickly returns to full awareness
 GENERALIZED SEIZURES CONT.

• Myoclonic
• Jerking or twitching movements occur in the arms, legs, or upper body
• Atonic
• Involve a loss of muscle tone and definition, ultimately leading to falls or an inability
to hold the head up
• Focal seizures
• May involve only part of the brain
• Unknown seizures
• Include epileptic spasms.
 ETIOLOGY

• In addition to epilepsy , seizures can be a symptom of many different conditions including:

• Genetic: genetic predisposition, it is still unclear if ethnicity plays a role in who develops
epilepsy, no gender is more likely to develop epilepsy than the other and can begin at any age
• Unknown: a neurological examination may diagnose the reason
• Structural/Metabolic: may arise during neurologic and nonneurological medical conditions
such as:
• Congenital conditions
• brain tumor
• Trauma (head injury)
• Cerebrovascular disease (stroke)
• Infection (meningitis, encephalitis, opportunistic infections of HIV)
• Degenerative brain disease
• Metabolic and toxic disorders (alcoholism, drug addictions, lead exposure)
• Complication of cancer
IMPLICATIONS

- Possibility of severe injury, accidents, embarrassment

- Patients can be legally restricted from participating in certain activities that
include:
- ~Vocation: occupations that involve use of machinery or require physical
activity
- ~Licenses: certain licenses provoked
- ~Independent living: due to health risk
CLINICAL MANIFESTATIONS

Precipitating Factors
Aura
PRECIPITATING FACTORS
• A patient may have factors that precipitate a seizure. The patient or a caregiver may provide helpful
information to prepare healthcare personnel to handle an emergency. Possible factors include the
following:
• Psychological stress
• Sensory stimuli (flashing lights, noises)
• Sleep deprivation
• Fever
• Use or withdrawal of alcohol
• Neonatal conditions
• Noncompliance with seizure medications

AURA
• The aura may be a special sensory stimulus (numbing, tingling, twitching)
• Not all patients are prepared for an aura before a seizure happens
• In the dental environment, the patient can inform the personnel so that the procedures can be
terminated
 PREVENTION

• 1. Primary prevention involves avoiding brain injury through use of protective

devices such as helmets

• 2. Secondary prevention involves early detection and compliance with

recommended treatment

• 3. Tertiary treatment involves interventions that decrease precipitating factors

•
 TREATMENT

• MEDICATIONS: Antiepileptic drug to control seizures

• A. Choices
• Patients may be placed on one antiepileptic drug or a combination of several
• Choice of therapy is related to type of seizure disorder
• B. Side Effects
• Each medication affects each patient to varying degrees.
• Side effects include:
- Increase or unknown risk of birth defects
- allergic reaction, rash
- Thrombocytoponeia
- fatigue/drowsiness/weakness/ataxia/headache
- Hirsutism, hypertrichosis
- nausea/vomitting
- Oral change of gingival enlargement associated with Phenytoin
- memory loss; behavioral and cognitive deficits
- Numerous drug interactions including: other antiepileptic drugs,
- damage to liver
acetaminophen, NSAIDS, erythromycins, reduction in efficacy of
- Leukopenia: delayed healing and infection
oral contraceptives
 TREATMENT CONT.

• ! ! Elderly and children are more sensitive to side effects of weakness, unsteadiness, and cognitive alterations ! !
• C. Precaution: Herbal Supplements
• Certain over-the-counter herbal supplements are used as a self-medication to help 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 gingko biloba, St.John’s wart, and some essential oils may affect dental treatment ****

• D. Surgery:
• A variety of surgical interventions are available and have become more precise through the advances in indentifying the
epileptogenic area through magnetic resonance imaging, tomography, and other analyses.
• -Resection of the epileptogenic area in the brain
• - If total restriction 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
 TRAUMATIC EFFECTS DURING SEIZURES

• Scarring of Lips and Tongue:

• Tongue, cheek, or lip may be bitten
• Scars may be observed during the extra/intra oral examinations
• 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 smoothed or restored
• May extend into the pulp of a tooth, allowing bacterial infection
 GINGIVAL HYPERPLASIA

• Gingival overgrowth occurs in 25-50% of people using Phenytoin.

• Other antiepileptic drugs also induce gingival overgrowth, but less frequently
• Phenytoin may cause fibroblasts and osteoblasts to deposit excessive extracellular matrix causing gingival
overgrowth
• Meticulous oral hygiene reduces the occurrence and severity!
• Occurrence:
• Incidence is higher in younger patients than in older patients beginning therapy
• Gingiva may start to enlarge within a few weeks or 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 as well
• Overgrowth of tissue surrounding dental implants can occur
TREATMENT:
-Change in prescription
-Nonsurgical treatment
-Surgical removal
 DIFFERENTIAL DIAGNOSIS OF MEDIC ATIONS
C AUSING GINGIVAL ENLARGEMENT

Numerous medications may cause gingival enlargement

• Antiseizure medications such as Phenytoin which is more frequent, than
ethosuximide, valproic acid, and primidone.
• Calcium channel blocking agents used for treatment of hypertension and other
diseases.
• Cyclosporin an immunosuppressant which is used frequently during an organ
transplant patient. Tacrolimus may be used as an alternative which has less
occurrence of gingival overgrowth.
 DENTAL HYGIENE CARE PLAN

• Most patients with epilepsy or a history of seizures need to receive the same
dental care as the general public.
• The dental team and other healthcare providers collaborate to provide the
best patient care.
• The patient with a seizure disorder may be under the care of other specialists
such as a neurologist, social worker, and the primary care physician.
 PATIENT HISTORY

• Most patients with epilepsy have a regular through medical examination

• 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
• The primary care provider will need to be contacted when the patient is
enable to provide needed information, is noncompliant, if seizure activity has
changed, and if epilepsy has had an effect on the oral cavity.
 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 is necessary, and a through nonsurgical
periodontal therapy is essential for patients who are taking/plan on taking an
antiseizure medication such as phenytoin, which may cause enlargement of the
gums.
 PRIOR TO AND AT THE START APPOINTMENT
FOR PATIENTS TREATED WITH PHENYTOIN
THERAPY

• A rigorous biofilm control program and complete scaling are introduced in

order to prepare for phenytoin therapy
• The patient (and caregiver) 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

• Nonsurgical treatment
• Frequent continuing care appointments
• Moderate gingival overgrowth
• Re-evaluation of the tissue
• Optimum level of oral health may be attained by changing their medication
• Sever fibrotic overgrowth
• Initial scaling and biofilm control
• Plans to change the drug or altering the dose
 CONTINUING CARE INTERVALS

• Frequent appointments on a 1, 2, to 3-month schedule . This depends of the

severity of the gingival enlargement and the patients ability and motivation to
maintain the oral cavity
• 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 after the diagnosis of the
disorder is essential for the overall health and well-being
 EMERGENCY CARE

Objectives
• Prevent body injury and accidents related to the oral structures, such as
• Tongue bite
• Broken or dislocated teeth
• Dislocated or fractured jaw
• Broken fixed or removable dentures
• Ensure adequate ventilation
 DIFFERENTIAL DIAGNOSIS OF SEIZURES

• Syncope (pass out/faint)

• 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

When the patients medical history shows indications for susceptibility

to seizures, advance preparation is advised to prevent complications
should a seizure occur
• 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
The dental clinic or office team has assigned responsibilities during
any emergency. Initiation of procedures for seizure emergency
follows a through preplanned routine.
• Make no attempt to stop the convulsion or restrain the patient
• Terminate clinical procedure; call for assistance
• Protect patient for injury
• Position patient: lower chair and tilt to supine; raise feet
• Keep patient from falling out of dental chair
• Push aside sharp objects, movable equipment and instrument trays
• Loosen tight belt, collar, necktie
• Do not place anything between the teeth
• Establish airway; check for breathing obstruction;
• Monitor vital signs
• Stay beside the patient to prevent personal injury and reassure
• Check for level of consciousness and determine if emergency medical
assistance is required
• When seizure is still occurring or has recurred within 5 minutes, activate
emergency medical system
 POSTICTAL PHASE

Postictal phase: The altered state of consciousness after an epileptic seizure

• Document emergency 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

The patient needs to present a 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
• 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.
 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