Our brain consists of millions of neurons, extensions and support between those neurons. It is often said that the brain houses more connections than there are stars in the Milky Way. Current estimates are that there are 86 million neurons in the brain and 200-400 million stars in the Milky Way, but you get the point. Neuroscientists are constantly discovering intricacies of the brain. They recently found a new kind of neuron – rosehip - but are unsure what it does. Transmitting electrical signals is how our brains function. Rumor has it our brains can light a low watt light bulb.

Seizures are defined as a sudden uncontrolled electrical disturbance of the brain. This may produce a physical convulsion, minor physical signs, thought disturbances or a combination of symptoms. The prevalence is anywhere from 0.5%-0.9% of the general population, effecting more men than women.

Research is limited on the influence of seizures in dental care. The focus has mainly been on gingival hyperplasia induced by antiepileptic medications. There is a huge need for dentists and implantologists to focus on this group of patients. Patients with seizure disorders have a propensity toward poor oral hygiene leading to decayed or missing teeth. They tend to also have trauma induced loss of teeth, abrasion, poor periodontal conditions and unfortunately dentists are likely to consider quick and simple procedures to help with their conditions. There are opportunities for dentists that place minimally invasive dental implants to help these patients in ways that other dentists can’t.

Something to keep in mind when placing implants for patients on antiepileptic medications is that they can be at an increased risk of fracture because enzyme inducing antiepileptic drugs alter the metabolism and clearance of vitamin D and have been associated with osteopenia and osteomalacia. To minimize the risk of fractures, such as ensuring adequate calcium and vitamin D supplementation (a minimum of 1,000 mg and 400 IU daily, respectively) especially in patients taking phenobarbital, phenytoin or primidone. Another drug, valproic acid can cause bone marrow suppression, which can impair wound healing and increase post-operative bleeding and infections. Decreased platelet count is the most common and best recognized hematologic effect of valproic acid; the incidence varies from 5% to 40%. Bleeding is a potential side effect that should be considered before surgery. In minimally invasive implantology the necessity for aggressive flap surgery is eliminated which may be an excellent option for these patients.  

Periodontal Concerns

50% of patients taking phenytoin within 12-24 months of initiation of the drug will develop gingival hyperplasia. Some clinicians will advocate the use of chlorhexidine, folic acid rises or both but excellent home care is the best at the prevention and decreasing the severity of the condition. Other oral manifestations of antiepileptic drugs may be xerostomia, stomatitis and even a rash.

Prosthetics

Epileptic patients who suffer from tonic-clonic seizures (grand mal)  with involuntary muscle contractions that include the masticatory system require special treatment. It is usually the recommendation to have fixed prosthesis instead of removable.

Drug interaction

It is extremely important that clinicians understand the jeopardy that certain medications can put the epileptic patient under. For instance, metronidazole, antifungal agents (such as fluconazole) and antibiotics (such as erythromycin) may interfere with the metabolism of certain antiepileptic drugs. Fluconazole and phenytoin is associated with a clinically significant increase in phenytoin plasma concentration, and may require adjustment to maintain safe therapeutic concentrations. Other anticonvulsants, such as vigabatrin, lamotrigine, levetiracetam, oxcarbazepine and gabapentin, are unlikely to interact with fluconazole.

Factors that Provoke Seizures

• Incorrect use of medications
• Sleep deprivation
• Drug abuse
• Excessive use of alcohol
• Excessive use of caffeine
• Hormonal changes
• Low blood sugar
• Deficiency of vitamin
• Electrolyte imbalance
• Congenital disease
• Medications that reduce the efficacy of antiepileptic medications
• Having appointments in the morning, kept short and reducing noise and bright lights can be helpful for reducing the incidence of a seizure. 

Actions to take if a patient has a seizure

• Clear all instruments away from the patient.
• Place the dental chair in a supported, supine position as near to the floor as possible.
• Place the patient on his or her side (to decrease the chance of aspiration of secretions or dental materials in the patient’s mouth).
• Do not restrain the patient.
• Do not put your fingers in his or her mouth (you might be bitten).
• Time the seizure (the duration of the event may seem longer than it actually is).
• Call 911 if the seizure lasts longer than 3 minutes.
• Call 911 if the patient becomes cyanotic from the onset.
• If possible, administer oxygen at a rate of 6–8 L/minute.
• Be aware of the possibility of compromised airway or uncontrollable seizure.
• If the seizure lasts more than 3 minutes and recurs, drug administration is required. There is conflicting data as to the administration of drugs. Some data recommends if the seizure lasts longer then 1 minute.

Once the seizure is over

• Do not undertake further dental treatment that day.
• Try to talk to the patient to evaluate the level of consciousness during the post-ictal phase.
• Do not attempt to restrain the patient, as he or she might be confused.
• Do not allow the patient to leave the office if his or her level of awareness is not fully restored.
• Contact the patient’s family, if he or she is alone.
• Do a brief oral examination for sustained injuries.
• Depending on post-ictal state, discharge the patient home with a responsible person, to his or her family physician or to an emergency room for further assessment. 

Fundamental principles to prevent seizures in the practice  

• Knowledge of the patient’s previous seizure episodes and medications
• Knowledge of the conditions that provoke epileptic seizures, in order to avoid them
• The ability to recognize the early signs of a seizure, take precautions before it occurs, and to provide the patient with supportive care. (Note epileptic patients many times have an aura before a seizure. An aura is a feeling, experience or movement that can be recognized by the patient.)

Patients with epilepsy can be safely treated in a dental practice. Dentists that understand epilepsy can be an invaluable asset and service for these patients and having the ability to provide proper oral care and promote systemic health will set your office apart.

Resources:

N. Aydemir, C. Ozkara, R. Canbeyli and A. Tekcan, “Changes in Quality of Life and Self-Perspective Related to Surgery in Patients with Temporal Lobe Epilepsy,” Epilepsy & Behavior, Vol. 5, No. 5, 2004, pp. 735-742. doi:10.1016/j.yebeh.2004.06.022

M. D. Turner and R. S. Glickman, “Epilepsy in the Oral and Maxillofacial Patient: Current Therapy,” Journal of Oral and Maxillofacial Surgery, Vol. 63, No. 7, 2005, pp. 996-1005. doi:10.1016/j.joms.2004.04.038

T. R. Browne and G. L. Holmes, “Epilepsy,” New Eng-land Journal of Medicine, Vol. 344, No. 15, 2001, pp. 1145-1151. doi:10.1056/NEJM200104123441507

J. Fiske and C. Boyle, “Epilepsy and Oral Care,” Dental Update, Vol. 29, 2002, pp. 180-187.

A. H. Friedlander and J. L. Cummings, “Temporal Lobe Epilepsy: Its Association with Psychiatric Impairment and Appropriate Dental Management,” Oral Surgery, Oral Medicine, Oral Pathology, Vol. 68, No. 3, 1989, pp. 288-292. doi:10.1016/0030-4220(89)90213-2

G. V. Busschots and B. I. Milzman, “Dental Patients with Neurologic and Psychiatric Concerns,” Dental Clinics of North America, Vol. 43, 1999, pp. 471-483.

Mehmet, Ö. Senem, T. Sülün and K. Hümeyra, "Management of Epileptic Patients in Dentistry," Surgical Science, Vol. 3 No. 1, 2012, pp. 47-52. doi: 10.4236/ss.2012.31008.

Karolyhazy K, Kovacs E, Kivovics P, Fejerdy P, Aranyi Z. Dental status and oral health of patients with epilepsy: an epidemiologic study. Epilepsia 2003; 44(8):1103–8.

Mattson RH, Gidal BE. Fractures, epilepsy, and antiepileptic drugs. Epilepsy Behav 2004; 5(Suppl 2):S36–40.

Sato Y, Kondo I, Ishida S, Motooka H, Takayama K, Tomita Y, and others. Decreased bone mass and increased bone turnover with valproate therapy in adults with epilepsy. Neurology 2001; 57(3):445–9.

Karolyhazy K, Kivovics P, Fejerdy P, Aranyi Z. Prosthodontic status and recommended care of patients with epilepsy. J Prosthet Dent 2005; 93(2):177–82.

Scott RA, Besag FM, Neville BG. Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial. Lancet 1999; 353(9153):623–6.

Scott RC. Buccal midazolam as rescue therapy for seizures. Lancet Neurol 2005; 4(10):592–3

Aragon CE, Burneo JG. Understanding the patient with epilepsy and seizures in the dental practice. J Can Dent Assoc. 2007 Feb;73(1):71-6. PMID: 17295949.