Managing patients who have seizure disorders: dental and medical issues BJ Sanders, JA Weddell and NN Dodge J Am Dent

Assoc 1995;126;1641-1647

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ARTICLE 2

DISORDERS: DENTAL AND MEDICAL ISSUES

BRIAN J. SANDERS, D.D.S., M.S.; JAMES A. WEDDELL, D.D.S., M.S.D.; NANCY N. DODGE, M.D.

MANAGING PATIENTS VYHO HAVE SEIZURE

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.,il.

Some dental professionals may

have concems about treating pa-

tients who have seizure disorders. The authors contend that

Qetween 0.3 and 0.7 percent of the U.S. population have a seizure disorder, and as many as 10 million people have been evaluated by a physician for this diagnosis.' The prevalence is highest in children between the ages of 2 and 5 years and at puberty, but the incidence of first-time seizures increases significantly after the age of 50, secondary to cerebrovascular disease.2
A seizure is a temporary involuntary disturbance of brain function that may be manifested as impaired consciousness, abnormal motor activity or behavior, sensory disturbances or autonomic dysfunction. This is accompanied by abnormal electrical discharges in the brain that usually, but not always, can be detected by electroen-

Increased knowledge about

seizures and how to manage

them may make dental profes-

sionals more comfortable. This

article reviews the various seizure types, discusses com-

monly used anticonvulsants and

their side effects and outlines
some special concerns dentists

may have In providing care to

these patients.

cephalography. Seizures are classified based on whether the abnormal electrical activity begins in a localized area (partial seizures) or throughout the brain (generalized seizures). Partial seizures are further classified according to whether or not consciousness is impaired, with simple partial seizures showing a variety of motor, sensory, autonomic or psychic symptoms but no impairment of consciousness. Partial complex seizures are associated with impaired consciousness. Partial seizures with secondary generalization also occur, during which the seizure initially is localized to one area of the brain and then spreads to involve both hemispheres.3 Generalized seizures, which affect the entire brain at the same time, may occur without warning. They are divided into several types, including tonic-clonic, myoclonic, atonic and absence seizures. Tonic-clonic seizures result in the loss of consciousness, and the incidence of injury caused by falling is great. The postictal period, or the recovery period after the seizure, is long. During this period the person may be confused or sleepy or may complain of a headache. Myoclonic seizures are brief muscle spasms that occur in clusters but usually do not result in a loss of consciousness. Atonic seizures are brief, involuntary losses of muscle tone that result in a significant number of injuries from falls. A person experiencing an atonic seizure may or may not lose consciousness. Absence, or petit mal, seizures consist of multiple brief episodes during which conJADA, Vol. 126, December 1995 1641

-C[INICA[ PRACIICE
sciousness is lost, with few, if any, motor manifestations. Simple absence seizures are brief-lasting less than 10 seconds-with atypical absence seizures lasting up to a minute. These seizures may be mistaken for daydreaming. Another type of seizure is the febrile seizure. These usually are generalized tonic-clonic seizures with a postictal phase that occur in children between 6 months and 5 years of age during a febrile illness. The episode is not considered a febrile seizure if it accompanies a traumatic injury or other metabolic cause. Febrile seizures occur in 2 to 5 percent of the U.S. population, and 40 percent of those affected have had more than one episode.4 There is usually no medication unless the seizures occur repeatedly. Children who have had febrile seizures usually have a normal EEG and normal lab values within one week of the seizure.4 Status epilepticus is seizure activity that occurs with such frequency that the seizures are almost continuous with no time between for recovery. Status epilepticus can be associated with any type of seizure, but it is most often a generalized tonic-clonic seizure. The risks of status epilepticus include airway compromise, acidosis, hypotension, hypertension, hyperthermia, cerebral edema, hypoglycemia and possible deterioration of central nervous system functioning following the verse effects, age, gender and cost all become factors in medication selection. Currently, phenobarbital and phenytoin (Dilantin, Parke-Davis) are the most commonly prescribed seizure medications, but carbamazepine (Tegretol, Basel Pharmaceuticals) and valproic acid (Depakene, Depakote, Abbott Laboratories) are being prescribed more frequently for patients with seizure disorders.5 Patients who have seizures typically take a single medica-

Because several drugs are equally effectivefor controlling seizures, adverse effects, age, gender and cost all becomefactors in medication selection.

tion in dosages sufficient to maintain therapeutic concentrations. The table lists typical therapeutic levels, but the final determination of dosage is individualized as some patients develop toxicity at lower concentrations than others.
ANTICONVULSANT MEDICATIONS

episode.3'4
The correct diagnosis of the seizure is important so that the appropriate anti-epileptic medication may be given. Because several drugs are equally effective for controlling seizures, ad1642 JADA, Vol. 126, December 1995

Phenytoin. Phenytoin was first introduced in 1938 and is widely used to treat partial and generalized tonic-clonic seizures. It has proven to be one of the best tolerated anticonvulsants and has an unusually high therapeutic index. Phenytoin can be taken orally, in capsule form, or intravenously. It is not indicated for intramuscular injection because of poor absorption and crystallization in the muscle. Alcohol use on a regular basis may increase phenytoin

clearance, and blood level concentrations should be carefully monitored in patients known to consume alcohol regularly. Chronic effects associated with phenytoin include gingival hyperplasia, hirsutism and coarsening of the facial features. Phenytoin also can alter the metabolism of vitamin D, which can result in bone disorders such as osteomalacia and hypocalcemia. Factors that increase the risk of osteomalacia are a low dietary intake of vitamin D, minimal exposure to sunlight and concomitant therapy with other anticonvulsant medications or use of exogenous male hormones. Blood dyscrasias are unusual, but there have been documented cases of leukopenia and bone marrow suppression. Most analgesics can be taken safely with phenytoin. If well-monitored, patients are capable of taking phenytoin for many years with good seizure control.34 Carbamazepine. Carbamazepine is pharmacologically related to tricyclic antidepressants. It is useful in controlling partial complex and generalized tonic-clonic seizures. It is only available in an oral form. Carbamazepine has a relatively short half-life that results in daily fluctuations and necessitates frequent daily dosing. Concomitant use with phenytoin increases the clearance time of carbamazepine significantly, resulting in higher dosage requirements. Carbamazepine is equal to phenytoin in anti-epileptic properties. It is widely prescribed by physicians because it does not cause gingival hyperplasia or hirsutism. Adverse effects include blood dyscrasias (including aplastic anemia), ex-

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CLINICAL PRACTICE-'
TABLE

DRU43

YHERAPEUVIC LEVELS
10-20 ig/mL

IrYPE OF SEIZURE

SIDE EFFECYS

Phenytoin (Dilantine, Parke-Davis)

Generalized seizures Partial seizuires

Gingival hyperplasia Fever PGastric distress

Drowsiness Ataxia

Megaloblastic anemia

Hirsiitism
Phenobarbital
15-30 mg/mL.

Generalized seizuires Partial seizuires Febrile seizures

Geeneralized seizures Partial seizures Psychomotor

Drowsiness Rash

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Ataxia

Carbamazepine (Tegretol, Basel Pharmaceviticals)

4-12 mg/dL

Headache Drowsiness Gait distuirbances

Bo
scrasias

seizures

Clonazepam (Kloniopin, Roche Laboratories)

13-72 mg/mLI

G-eneralized seizures Minor motor

Drowsiness
Ataxia

seizuires

Absence seizures (petit mal) Atonic seizures

Depression Tremor Hair loss

Hirstitism

Valproic acid (Depakote, Abbott

50-100 Ztg/mL,

Laboratories)

seizuires Absence seizuzres

. M\!ajor motor seizures

Generalized

Miinor motor seizuires

Primidone (Mysoline,
5-12 mg/mL,

Nausea Twitching miver toxicity Gastrointestinal disturbances Altered bleeding time

Wyeth-Ayerst L.aboratories)

Generalized seizLires Partial seizures

Gastric distuirbances Naiisea Vomiting

Anorexia
Dermatitis

Blood dyscrasias

foliative dermatitis and jaundice. Propoxyphene (Darvon, Eli Lilly & Co.) and erythromycin

should not be taken with carbamazepine because they significantly increase the blood levels of carbamazepine. Analgesics

that may be used safely with carbamazepine include aspirin, acetaminophen and ibuprofen.3 Valproic acid. Valproic acid
JADA, Vol. 126, December 1995 1643

rnC[INICAI.

PACIICL-

has a broad spectrum of antiepileptic activity and is useful in preventing generalized absence, myodonic and generalized tonic-clonic seizures. It is administered orally and is water soluble; it is not available as a parenteral. Valproic acid also may be given rectally if the patient is unable to take it by mouth. The most common side effects are nausea and vomiting. Other possible side effects include changes in appetite, sedation and hair loss. Fatal hepatoxicity similar to that in Reye's syndrome has occurred in children younger than 2 years taking multiple anticonvulsants.6 Valproic acid may decrease platelet count and function, and its use may increase bleeding; therefore, aspirin and ibuprofen are contraindicated. Other blood dyscrasias (such as anemia, leukopenia) also may
occur.3'4

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Figure 1. Thil

paVont developed pnenytomn-mnduoo

gingva. nyperpover-

ssa and was scheduled for

elotrobautery to romove the tlsue

growth.

Barbiturates. The two most

widely used barbiturates are phenobarbital and primidone (Mysoline, Wyeth-Ayerst Laboratories). They are indicated for partial and generalized tonic-clonic seizures. Phenobarbital is available in oral and parenteral forms. It has a long half-life and may be given once a day, usually at night, to avoid the drowsiness associated with it. This once-aday dosing also may be helpful when compliance is a problem. Primidone is metabolized into phenobarbital and phenylethylmalonamide, and it occasionally proves useful in patients whose generalized tonic-clonic seizures are not well controlled with other anticonvulsants. Drugs that increase the activity of hepatic enzymes such
1644 JADA, Vol. 126, December 1995

as warfarin (Coumadin, DuPont Pharma), hydrocortisone and digoxin (Lanoxin, Burroughs Wellcome) may lower the blood phenobarbital levels. Bone marrow suppression is rare, but complications related to folate deficiency, hypocalcemia and osteomalacia may occur.3 Succinimides. Ethosuximide (Zarontin, Parke-Davis) is the most commonly used succimmide prescribed specifically for the control of generalized absence seizures. It is available only in an oral form. Its half-life is 30 hours in children and 50 hours in adults. There are few side effects, the most common being nausea and vomiting.3 Benzodiazepines. The most commonly used anticonvulsants in this class are diazepam (Valium, Roche), lorazepam (Ativan, Wyeth-Ayerst Laboratories) and clonazopam (Kionopin, Roche). These drugs are rapidly absorbed orally and diazepam and lorazepam are approved for parenteral administration. Diazepam and lorazepam are

used to treat status epilepticus because of their rapid distribution to the brain. Clonazepam is effective in treating myoclonic
seizures.3

Newer anticonvulsants. Several new anticonvulsants are becoming available for use in the United States. These include lamotrigine (Lamictal, Burroughs Wellcome) and gabapentin (Neurontin, ParkeDavis). They appear to have low toxicity, which means routine monitoring of drug levels and other laboratory values is not required.7
MEDICAL CONSIDERATIONS

Most people who have seizure disorders attain good control of their seizures and are capable of receiving routine dental care. The dentist needs to be familiar with the seizure medication that the patient is taking and be aware of the side effects associated with it. This is especially important if the patient requires extractions or antibi-

CLINICAL PRACTICE
gains consciousness is significantly more serious and may
be an indication of status
epilepticus.4'8

Figure 2. The same patlent givectomy.

as

In Flgure

Immediately after the

gin-

otic therapy. There is no one theory for the pathogenesis of seizures; they can be triggered by many things such as anxiety, illness, fatigue, metabolic changes and hyperventilation. When obtaining the patient's medical history, it is important to find out the seizure frequency, how long the seizures last, whether the patient loses consciousness or stops breathing,
when the last seizure occurred and how the seizures usually are controlled. It is also important to find out the patient's typical condition after a seizure (for example, is he or she confused or sleepy, or does he or she have headaches?). The office staff must be sensitive to the embarrassment that many individuals feel after a seizure, and they must make every effort to make the patient comfortable. Many patients will suffer a partial loss of memory near the time of the incident, and some patients become incontinent during a seizure, further elevating their

self-consciousness. Do not be alarmed if the patient is initially hard to arouse, as people often fall into a deep sleep after a seizure. It is usually best to defer dental treatment when a patient has had a moderate to severe seizure, but a mild seizure may go unnoticed and usually will not interfere with treatment if the patient wishes to continue. Patients who have grandmal, tonic-clonic seizures may be able to describe a sensation or aura before losing consciousness. The patient then experiences a brief period of muscle rigidity (10 to 20 seconds). This is followed by generalized musculoskeletal contractions and relaxations that last from two to five minutes. During the postictal phase, which can last from 10 to 30 minutes, the muscles relax and the respiratory and cardiovascular systems are depressed. Full recovery may take up to three hours. A seizure that stops and returns before the patient re-

The first step in managing a seizure in the dental office is to protect the patient from further injury. The dental chair should be placed in the supine position and as close to the floor as possible. Do not place anything in the patient's mouth to prop it open, such as mouth props or a tongue blade, as this may cause further injury. Be sure to open the airway to allow adequate exchange of oxygen. This is best accomplished by positioning the head so that it is flexed and the neck extended. It may help to place a rolled towel under the patient's shoulders. Suction the oropharynx for any excessive secretions that could obstruct the airway. Obtain vital signs such as heart rate and blood pressure and be sure to contact the emergency medical service as soon as the seizure begins to ensure prompt medical attention and followup.8,9 As stated previously, recurrent seizures can be life-threatening. These must be treated promptly to avoid neuronal damage, altered cerebral metabolism, acidosis and hypoxia.'0

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Patients with recurrent usually are stabilized with anticonvulsant medications given intravenously. Unless your office staff is trained in the pharmacological management of seizures, this should be managed by the EMS personnel. The current drug of choice to control recurrent seizures is lorazopam given at a dose of 0.05 to 0.1 milligram/kilogram. Diazepam also may be given at doses of 0.2 to
seizures

JADA, Vol. 126, December 1995 1645

-CLINICAL PRACIICE0.5 mg/kg, but lorazepam has been found to have a longer half-life and is less likely to cause respiratory depression and hypotension.
DENTAL CONSIDERATIONS

The presence of a seizure disorder can influence some treatment decisions. For example, decisions regarding prosthetics can be affected by the, likelihood of seizures. As a general rule, it is better to place a fixed prosthesis than a removable appliance because the removable prosthesis can dislodge during a seizure. Also, placement of complete metal units should be considered as they can minimize the chance of a fracture. Likewise, use of acrylic facings on anterior crowns can facilitate repair should a fracture occur."'12 The most significant oral complication related to seizure medication is gingival hyperplasia secondary to phenytoin therapy. About half the patients placed on phenytoin will show evidence of gingival enlargement, usually within two to 18 months after initiation of the medication. The etiology is still unknown, but there appears to be an increase in the number of fibroblasts in the connective tis-

order of severity, are - facial surfaces of the maxillary anteriors; - facial surfaces of the mandibular anteriors; - buccal surfaces of the maxillary posteriors; - buccal surfaces of the mandibular posteriors. The lingual surfaces are affected to a lesser degree. The tissue overgrowth may lead to delayed eruption of the teeth, misalignment, retention

As a general rule, it is better to place afixed prosthesis than a removable appliance because the removable prosthesis can dislodge during a seiure.

oral hygiene, the patient should be encouraged to maintain a stringent hygiene routine. A positive-pressure appliance may be used to prevent future growth of the gingiva. The appliance should be placed immediately after surgery and should be worn at night and usually three hours during the day. Pressure appliances also can retard the growth of the hyperplastic tissue in instances where surgery is contraindicated. Place patients who have gingival hyperplasia on a threemonth recall. This will help ensure immaculate oral hygiene. One study also suggests that a topical application of stannous fluoride as part of the patient's oral hygiene routine will help control the gingival

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overgrowth.'8
CONCLUSION

sues.'3 Gingival hyperplasia may

occur at any age, but it seems to affect younger patients to a greater degree than adults. Men and women are equally affected. There does not appear to be a correlation between dosage and the incidence of gingival hyperplasia. There is strong clinical evidence of a correlation between poor oral hygiene and the amount of tissue overgrowth.'4"15 The gingival areas affected, in
1646 JADA, Vol. 126, December 1995

of food and debris, halitosis and an unsightly gingival appearance (Figure 1). Gingival overgrowth resolves itself in one to six months after withdrawal of the phenytoin16; with severe cases, it may be beneficial to consult with the patient's physician about alternative seizure medications to avoid some of these problems. If the hyperplasia interferes with oral function or esthetics, gingivectomy should be performed. The procedure can be performed by electrocautery or laser or with surgical instruments. If a full-mouth gingivectomy is performed in the operating room, electrocautery or laser is preferred because there is less bleeding, and it is usually not necessary to place a surgical dressing (Figures 1 and 2).'7 Because the incidence of recurrence is higher with poor

Patients with seizure disorders may be treated in the private dental setting. A thorough medical history should tell you - what type of seizures the patient has; - how well the seizures are controlled; - the frequency and duration of seizures; - what might trigger a seizure; - what to expect when the patient has a seizure. Familiarize yourself with the patient's seizure medications and the side effects associated with them. The information you obtain and document from the patient will make you and your staff more comfortable. The medical information also will enable you to be prepared for a seizure, possibly prevent one from occurring and provide better service to the patient overall. .

CLINICAL PRACTIICE
Dr. Sanders is an assistant professor, Department of Pediatric Dentistry, Indiana University, and an assistant professor, James Whitcomb Riley Hospital for Children, Indianapolis. Address reprint requests to Dr. Sanders, James Whitcomb Riley Hospital for Children, 702 Barnhill Drive, Room 1110, Indiana University Medical Center, Indianapolis, Ind. 46202-5200.

Dr. Weddell is an associate professor, Department of Pediatric Dentistry, Indiana University, and dental director, James Whitcomb Riley Hospital for Children, Indianapolis. Dr. Dodge is an associate professor, Department of Pediatric Dentistry, Indiana University, and an associate professor, James Whitcomb Riley Hospital for Children, Indianapolis.
1. Little JW, Falace DA. Dental management of the medically compromised patient.

3rd ed. Chicago: Mosby-Yearbook; 1988:27990. 2. Treiman DM. Current treatment strategies on selected situations in epilepsy. Epilepsia 1993;34(Supplement 65):517-23. 3. Cohen DW, ed. A symposium: the oral

manifestations of gingival hyperplasia. Compendium Contin Educ Dent 1990;Supplement 14:S490-S514. 4. Hirtz DG, Nelson KB. The natural hisotry of febrile seizures. Ann Rev Med 1983;34:453-71. 5. Millikan CH, ed. Seizure disorders: clinical management. Part II. Detroit: ParkeDavis; 1976:6-23. 6. Konig SA. Severe hepatotoxicity during valproate therapy: an update and report on eight new fatalities. Epilepsia 1994;35(5):1005-15. 7. Harden CL. New antiepileptic drugs. Neurology 1994;44(5):787-95. 8. Malamed SF. Managing medical emergencies. JADA 1993;124(8):40-51. 9. Selbst SM. Office management of status epilepticus. Pediatr Emerg Care 1991;7(2):106-9. 10. Pellock JM. Status epilepticus in children: update and review. J Child Neurol 1994;9(Supplement 2):S27-35. 11. Rucker LM. Prosthetic treatment for the patient with uncontrolled grand mal epileptic seizures. Spec Care Dentist 1985;5(5):206-7. 12. Braham RL, Casamassimo PS, Nowak AJ, Posnick WR, Steinberg AD. The dental implications of epilepsy. Rockville, Md.: U.S. Department of Health Education and

Welfare, 1977; DHEW publication no. HSA785217. 13. Stinnett E, Rodu B, Grizzle WE. New development in understanding phenytoin-induced gingival hyperplasia. JADA 1987;114:814-6. 14. Thomason JM, Seymour RA, Rawlins MD. Incidence and severity of phenytoin induced gingival overgrowth in epileptic patients in general medical practice. Community Dent Oral Epidemiol 1992;20:288-91. 15. Modeer T, Dahllof G. Development of phenytoin-induced gingival overgrowth in non-institutionalized epileptic children subjected to different plaque control programs. ACTA Odontol Scand 1987;45(2):81-5. 16. Dahllof G, Axio E, Modeer T. Regression of phenytoin-induced gingival overgrowth after withdrawal of medication. Swed Dent J 1991;15(3):139-43. 17. Jones JE, Weddell JA, McKown CG. Incidence and indications for surgical management of phenytoin-induced gingival overgrowth in a cerebral palsy population. J Oral Maxillofac Surg 1988;46:385-90. 18. Steinberg AD. Clinical management of phenytoin-induced gingival overgrowth in handicapped children. Pediatr Dent 1981;3(Special Issue):130-6.

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JADA, Vol. 126, December 1995 1647