EPILEPSY patient and dental treatment protocol

 

EPILEPSY patient 

and dental treatment protocol

GENERALIZED: GRAND MAL  

        

(TONIC-CLONIC) EPILEPSY

Grand-mal epilepsy usually begins in childhood, or sometimes at about puberty. There is a warning (aura), followed by loss of consciousness, tonic and the clonic convulsions and, finally, a variably prolonged recovery.

The aura may consist of a mood change, irritability, brief hallucination or headache. The attack then begins suddenly with total body tonic spasm and loss of consciousness. The sufferer falls to the ground and is in danger of injury. Initially the face becomes pale and the pupils dilate, the head and spine are thrown into extension (opisthotonos), and glottic and respiratory muscle spasm may cause an initial brief cry and cyanosis. There may also be incontinence and biting of the tongue or lips. The tonic phase passes, after less than a minute, into the clonic phase, when there are repetitive jerking movements of trunk, limbs, tongue and lips. Salivation is profuse with bruxism, sometimes tongue-biting and, occasionally, vomiting. There may be urinary or faecal incontinence, and autonomic phenomena such as tachycardia, hypertension and flushing. Clonus is followed by a state of flaccid semi-coma for a further 10-15 min. Confusion and headaches are common afterwards and the patient may sleep for up to 12 h or more before full recovery. The attack may occasionally be followed by a transient residual paralysis (Todd palsy) or by automatic or aggressive behaviour. This full sequence is not always completed.

Complications of major convulsions can be trauma , respiratory embarrassment or brain damage, or progress to status epilepticus, but most seizures end without mishap. A major fit is so dramatic that it seems to be of longer duration than is in fact the case but, if it lasts more than 5 min (by the clock) or starts again after apparently ceasing, the patient must be regarded as being in status epilepticus, which is particularly dangerous - the mortality rate can be up to 20%. Brain damage may result from cerebral hypoxia, when tonic and clonic phases alternate repeatedly without consciousness being regained and there can also be inhalation of vomit and saliva. Status epilepticus is a medical emergency by causing severe hypoxia, and is potentially fatal.

PARTIAL SEIZURES "Petit-mal seizures"

Petit-mal seizures come most often during childhood and are characterized by minimal or no movements (except for eye- blinking) and an apparently blank stare; brief sudden loss of awareness or of conscious activity that may only last seconds; recur many times and involve learning difficulties (child often thought to be day dreaming). Most patients who have petit mal also have grand-mal attacks.

Simple partial (focal) seizures can be motor, sensory or behavioural, typically remain confined to one area, and include muscle contractions of a specific body part [focal motor epilepsy, which may take the form of clonic movements of a limb or group of muscles, usually in the face, arm or leg though the clonus may spread (march) to adjacent muscles on the same side of the body (Jacksonian epilepsy)]; abnormal sensations; sometimes nausea, sweating, skin flushing, and dilated pupils; sometimes other focal (localized) symptoms.

Partial complex seizures, or temporal lobe epilepsy (psychomotor epilepsy), are characterized by automatism (automatic performance of complex behaviours) such as lip-smacking and chewing movements, or facial grimacing; recalled or inappropriate emotions; changes in personality or alertness; sometimes disorientation, confusion and amnesia, or loss of consciousness; sometimes olfactory (smell) or gustatory (taste) hallucinations or impairments.

 

DENTAL ASPECTS

Dental treatment should be carried out in a good phase of epilepsy, when attacks are infrequent. Various factors can precipitate attacks (Box 13.11).

Box 13.11 Factors sometimes precipitating fits in susceptible subjects

·         Withdrawal of anticonvulsant medication

·         Epileptogenic drugs (Box 13. 12)

·         Fatigue, starvation or stress

·         Infection

·         Menstruation

·         Flickering lights (television; strobe lights)

Those who have infrequent seizures or who depend on others (such as those with a learning impairment) may fail to take regular medication and thus be poorly controlled. When carrying out dental treatment in a known epileptic, a strong mouth prop should be kept in position and the oral cavity kept as free as possible of debris. As much apparatus as possible should be kept away from the area around the patient. Drugs can be epileptogenic or interfere with anticonvulsants, or can themselves be changed by anticonvulsant therapy and may, therefore, be contraindicated (Tables 13.32 and 13.33 and Box 13.12).

In the past, particularly, gingival swelling due to phenytoin required treatment by gingival surgery. Carbamazepine or gab- apentin obviate this problem.

 

 

Box 13.12 Drugs contraindicated in epilepsy

·         Alcohol

·         Chlorpromazine

·         Enflurane

·         Flumazenil

·         Fluoxetine

·         Ketamine

·         Lidocaine (large doses)

·         Metronidazole

·         Quinolones

·         Tramadol

·         Tricyclic antidepressants

Aspirin, azoles and metronidazole can interfere with phenytoin. Propoxyphene and erythromycin can interfere with carbamazepine.

Large doses of lidocaine given intravenously for severe arrhythmias may occasionally cause convulsions. An overenthusiastic casualty officer may therefore blame a dental LA for causing a fit. There is no evidence that this can happen, especially as intravenous lidocaine has also been advocated for the control of status epilepticus.

Conscious sedation in epilepsy should be safe. Stress reduction should reduce the chance of a fit. Benzodiazepines are anti-epileptogenic, but occasionally fits have been recorded in epileptics undergoing intravenous sedation with midazolam. Flumazenil, however, can be epileptogenic. Nitrous oxide can increase the CNS depression in patients on anticonvulsants. It is probably best to avoid electronic dental analgesia.

Acrylic is probably better used for prostheses than porcelain, as it is more resilient.

Convulsions may have craniofacial sequelae, especially lacerations, haematomas and fractures. Trauma frequently results from a grand-mal attack when the patient falls unconscious or

from the muscle spasm, and a range of injuries can result [e.g. fractures of the vertebrae or limbs, dislocations, periorbital subcutaneous haematomas in the absence of facial fractures, injuries to the face from falling (lacerations, haematomas, fractures of the facial skeleton), fractures, devitalization, subluxation or loss of teeth (a chest radiograph may be required), TMJ subluxation, or lacerations or scarring of the tongue, lips or buccal mucosa].

FEBRILE CONVULSIONS

Febrile convulsions are more common than epilepsy, usually affect children and result from a rise in body temperature commonly caused by infection. Children who develop high fevers (above 38°C) should therefore be put in a cool environment, and bathed with tepid water and given acetaminophen elixir (not aspirin). Children under 18 months should be admitted to hospital since the fit may be due to meningitis. Severe febrile convulsions can cause brain damage and about 3% of children with febrile convulsions go on in later life to develop epilepsy; most do not.

For more reading download :

👆Dental management of medically compromised patient PDF

👆Crispian skully medical proplems in dentistry

👆 Contemporary oral and maxillofacial surgery PDF

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