EPILEPSY AND DENTAL MANAGEMENT

General description. Epilepsy is a term that describes a group of disorders characterized by chronic, recurrent, paroxysmal changes in neurologic function (seizures) that are caused by abnormal electrical activity in the brain. Seizures may either be accompanied by motor manifestations or manifested by sensory, cognitive or emotional changes in neurologic function. This discussion will be limited to generalized tonic-clonic seizures, since these represent the most severe expression of epilepsy that practitioners are likely to encounter.

Epidemiology. It is estimated that 10% of the population will have at least one epileptic seizure in its lifetime and that the overall incidence rate is 0.5%.¹ Seizures are most common during childhood, with as many as 4% of children having at least one seizure during the first 15 years of life. Fortunately, most children outgrow this.²

Etiology and clinical presentation. Common causes of epilepsy include head trauma, intracranial neoplasm, hypoglycemia, drug withdrawal, and febrile illness. For many patients, however, there is no known cause (idiopathic epilepsy). In such cases, seizures are sometimes evoked by a specific stimulus such as flickering lights, monotonous sounds, music, or a loud noise.

The patient having a generalized tonic-clonic convulsion (grand mal seizure) typically emits a sudden cry, immediately loses consciousness, exhibits generalized muscle rigidity followed by clonic activity consisting of uncoordinated beating movements of the limbs and head, ceases movement and becomes comatose. Within a few minutes, the patient gradually returns to consciousness with stupor, headache, and confusion.

Treatment. The medical management of epilepsy is based on drug therapy. While phenytoin (dilantin) is most commonly used as a first line of treatment, other anticonvulsant drugs such as carbamazepine, phenobarbital, and valproic acid are also commonly used.

Medical considerations. Once an epileptic patient has been identified:

• Learn as much as possible about the seizure history, current medications, degree of seizure control, and any known precipitating factors.
• Be aware of the adverse effects of anticonsulvants (drowsiness, dizziness, ataxia, and gastrointestinal upset).
• Render normal routine care to epileptic patients who have attained good control of their seizures with medication.
• Do not render treatment to patients whose seizure activity does not respond to anticonvulsants, without prior consultation with the patient's physician. Such patients may require additional anticonvulsant or sedative medication, as directed by the physician.

Oral complications. The most significant oral complication seen in epileptic patients is gingival hyperplasia associated with phenytoin. The anterior labial surfaces of the maxillary and mandibular gingivae are the most severely affected. While there is some controversy regarding the effectiveness of oral hygiene in preventing gingival hyperplasia, most evidence suggests that meticulous oral hygiene will prevent, or at least, significantly decrease its severity. Good home care should thus be combined with the removal of irritants such as overhanging restorations and calculus. Surgical intervention may, however, be required to reduce hyperplastic tissue interfering with function or appearance.

Dealing with a seizure. Should a patient have a generalized tonic-clonic convulsion in the dental office, be prepared to deal with it. The primary task of management is to protect the patient and try to prevent injury.

• Do not attempt to move the patient.
• Place the chair in a supported supine position.
• Turn the patient, if possible, to the side to control the airway and minimize aspiration of secretions.
• Use passive restraint only to prevent injury from hitting nearby objects or from falling out of the chair.

Potential Drug Interactions.

• Propoxyphene and erythromycin should not be administered to patients taking carbemazepine because of interference with metabolism of carbemazepine, which could lead to toxicity.
• Aspirin and NSAIDS should not be administered to patients taking valproic acid, for they can further decrease platelet aggregation, leading to hemorrhagic episodes.

PRIMARY REFERENCE

Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 4th ed. St Louis, MO: MosbyYearBook, Inc; 1993: 328-334.

ADDITIONAL REFERENCES

1. Engel J: The epilepsies. In Wyngaarden JB, Smith LH, Bennett JC, eds. Cecil Textbook of Medicine, 19th ed, vol 2. Philadelphia: WB Saunders; 1992.
   
   
2. Dodson WE, Prensky AL, DeVivo DC et al. Management of seizure disorders: selected aspects. I, J Pediatr 1976; 89: 527-540.