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Dental concerns and management of children with Epilepsy: An overview

Nirmala SVSG

Professor, Department of Paedodontics & Preventive Dentistry, Narayana Dental College & Hospital, Nellore, India

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Saikrishna Degala

Professor & HOD, Department of Ora and Maxillofacial Surgery, JSS Dental College & Hospital Mysore, Karnataka State, India

DOI: 10.15761/DOMR.1000356

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Abstract

Modem medicine defines epilepsy as a chronic neurologic disorder characterized by frequently recurrent seizures. A seizure is a sign of a disease, which manifests as an episodic disturbance of movement, feeling, or consciousness caused by sudden synchronous, inappropriate and excessive electrical discharges that interfere with the normal functioning of the brain site of location of seizures the disease occurs independent of race, age and gender ]. However, epilepsy has been occur more frequently in men than in women. oral manifestations are soft tissue lacerations of tongue or buccal mucosa, avulsion, luxation and fractures of teeth and jaws are more common and also subluxation of the temporo mandibular joint.due to drug therapy gingival hyperplasia, recurrent apthous like ulceration and anomalous dental development like small teeth and delayed eruption.reduce stress on the patients with psychobehavioral preparations, sedation etc. Diazepam is the drug of choice because it has anticonvilsant properties.The use of conscious sedation and general anesthesia is not contraindicated in patients’ epilepsy. In some situations nitrous oxide or intravenous sedation may be necessary to safely and effectively provide dental care. Avoid IV local anesthetics. Appointments should be short, importance of tooth brushing procedures and regular review, if appliances are indicated for tooth movement and tooth replacement, fixed type are preferred. This article discuss about etiology, clinical features and dental management of children with epilepsy.

Key words

children, epilepsy, dental management, oral health

Introduction

The word “epilepsy” is derived from the Greek word take or to seize. Between 400 BC and 260 AD Hippocrates.Epilepsy is not a disease in itself but is a symptom of an underlying brain disorder [1,2]. It occurs in 0.5 to I per cent of the population and about 5 per cent of them have mental subnormality [3]. Its prevalence in developing countries like India being 5.59 per 1000 people and that in developed countries, being 5-7 per 1000 people [4]. More than 1.5 million Americans have active epilepsy [5]. It is present in about half of all spastics and a quarter of athetoids. Seizures are more common in children than adults but included in this are those children who have convulsions with a sudden rise in temperature associated with a febrile condition which are most common between the ages of 18 months and 3 years [6,7].

Classification [8,9]

1.There are two types of epilepsy:

The organic variety in which physical brain damage can be shown and in these there may be some genetic factor such as phenylketonuria; and

The idiopathic variety in which there is usually a functional brain abnormality demonstrable.

2. Based on the involvement of the Area there are two types.

Localised : Where it affects only a part of the body.

Generalised: where the multiple areas are involved

3. International Classification of the Epilepsies represented in table 1.

Table 1. showing classification of Epilepsy

1.

localization related (focal,partial)

Idiopathic

Benign childhood epilepsy with centrotemporal spikes

Childhood epilepsy with occipital paroxysms

Primary reading epilepsy

Symptomatic

Temporal lobe epilepsy

Frontal lobe epilepsy

Parietal lobe epilepsy

occipital lobe epilepsy and childhood

2.

Generalised

Idiopathic

Epilepsy with myoclonic astatic seizures

Benign neonatal familial

Childhood absence epilepsy

Juvenile absence epilepsy

Generalised tonic-clonicepilepsy

Symptomatic

Nonspecific etiology

Early myoclonic encephalopathy

Early infantile encephalopathy

Specific syndrome etiology

Congenital malformations

Inborn error of metabolism

3,

Cryptognic

West syndrome

Lennox-kleffner syndrome

Myoclonic absence seizure

Epilepsy with myoclonic astatic seizures

4.

Undermined origin

Neonatal seizures

Landau-Kleffner syndrome

Seizures during sleep with continuous spike wave

5.

Special design

Reflex originated epilepsy

Isolation

Situation related

Clinical features

The seizure which occurs is due to a sudden discharge in the grey matter like an electric shock. It is of varying degrees depending on where and how much of the brain is involved in the discharge. Grand mal is a major seizure which may be preceded by a warning of either visual or motor type, or with irritability or headache shortly before the attack. At the onset there is a sudden tonic spasm over the whole body with loss of consciousness. There is facial pallor, dilated pupils, with the eyeballs usually rolled upwards and the head thrown back. The body is stiffened and rigid. The tongue may be bitten when the jaw muscles contract. The pallor of the face quickly changes to cyanosis and within half a minute of the onset the clonic phase follows. The patient eventually wakes with a headache and is in a state of mental confusion. Petitmal is a lesser form of seizure where there is only momentary loss of consciousness, though there may be other minor effects. It lasts for less than half a minute and may be referred to as a ‘dizzy spell’ or the patient may be unaware that it has occurred. It is rarely associated with mental subnormality. Occasionally, types of seizure occur other than grand and petit mal which show a variety of behaviour patterns and are classified as psychomotor, focal and infantile myoclonic (Tables 2 and 3) [12-14].

Table 2. Syndromes associated with Epilepsy [10,11]

1.

Dravet syndrome

2.

West sndrome

3.

Lennox-Gastaut syndrome

4.

Landau-Kleffner syndrome

Table 3. showing oral manifestations

1.

Self-injury due to seizures and surroundings

2.

Traumatic injuries such as avulsion, luxation Dentoalveolar fractures

3.

Dentoalveolar fractures

4.

Facial fractures

5.

Erythematous gingivae

6.

Gingival hyperplasia due to antiepileptic drug

7.

Secondary infection on the fibrous overgrowtl

8.

Gingival hyperplasia induced malocclusion

9

Malodor and poor oral hygiene

10

Cervical lymphadenopathy

Treatment of these convulsive conditions is by the use of drugs to suppress the episodes. These are most frequently Epanutin (Dilantin) or one of the barbiturates with Mysoline, though others are also used. Occasionally, a ketogenic diet also may be followed. A very positive attempt is being made to fit these patients into normal community living and to try to educate the public to accept them [15].

Oral condition

The only special feature is in those patients who are being treated by Epanutin. In these, there may be hyperplastic gingivitis of a fibrous nature and it may be so severe as to cover most of the crowns of the teeth, or cause delayed eruption. It is particularly associated with a poor state of oral hygiene. It is well illustrated in many textbooks of oral pathology [16].

Dental treatment

Many of these patients are particularly apprehensive and time taken in getting to know them is well spent. It is useful to ask the parent how long it has been since the last seizure and what type of occasion brings it on. From this one can judge the likelihood of such an episode occurring in the dental surgery [17]. Usually, the child is under quite good control and is most unlikely to have one during treatment, especially if there is a good relationship between the child and the dentist. If a patient suffering from grandmal attends for dental treatment, it is as well that the surgery assistant should know the procedures should a seizure occur. The patient is immediately put in a place from which he cannot fall, and a clear space on the hour is the easiest. He should be placed on his side with his head in a position to prevent aspiration of saliva into the lungs. An instrument may need to be pushed between his teeth before full spasm of the jaw muscles has occurred to prevent tongue biting but damage to teeth and to soft tissues must be avoided. In the dental surgery the most suitable instrument that is easily available is the plastic mixer for alginate which is tough but resilient and will not cause trauma. If the patient does not come out of his seizure quite quickly, and the parent will give advice on the normal pattern, then he should be given oxygen if severely cyanosed and arrangements made to have him taken to hospital immediately. When he comes out of his seizure normally he will have a headache and be mentally confused, so that further treatment should be postponed apart from minor adjustments necessary to tidy up the operation which was interrupted [18-20].

Conservation can be carried out normally A rubber dam must be used in light of the risk of seizure during restorative treatment, composite materials are beneficial for incisor teeth restoration. Metal temporary crowns or implant-supported-bridges are more practical than amalgam or porcelain restorations because of the risk of damage during seizures [13].

Local anaesthesia can be used. In the case of general anaesthesia, however, only a very experienced anaesthetist should give the anaesthetic providing he considers the patient suitable. The parent should be reminded that the normal drug dose must be given prior to the appointment and not to omit it [19]. Kennedy et al. reported that, in dental practices, local anesthetics administrated in therapeutic dosages do not interact with standard antiepileptic drugs. In the case of a critical overdose of local anesthetic, however, clinical conditions such as generalized tonic-clonic convulsions may be observed. Although it has been reported that local anesthetic administration during dental treatment is safe. Local anesthesia should be preferred to general anesthesia as far as possible during the treatment of epileptic patients. This is because the brain may suffer from temporary anoxia during general anesthesia, which may initiate epileptic seizures [20].

The periodontal condition may need special attention in those patients on Epanutin. Scrupulous scaling and cleaning should be done regularly and the patient and his parent taught proper tooth brushing [21]. If the hyper plastic gingivitis is severe, there may be the need for gingival surgery but the condition tends to recur. If it causes a great problem, and it may do so especially in those who are mentally normal and are upset by the appearance, then it would be reasonable to discuss it with the physician to see if the Epanutin can be changed to an alternative therapy [22].

Light can be a trigger in inducing an epileptic seizure. Therefore, be used as eye protection and the operating light must be controlled into the mouth and not flashed into the patient’s eyes.

Most patients with epilepsy or a seizure disorder can either or know whether they are likely to have a seizure during the office. If patients are adequately controlled with their medication, relatively simple and straight forward.

Patients whose seizure activity does not respond to anticonvulsants may have to have a consultation with a neurologist prior to a dental appointment. Such additional anticonvulsant or sedative medication [21].

Some of the epileptic patients may hide their disorder for fear of being coalesced dental treatment or they consider epilepsy as an awkward disease. In this case the subject matter requested on the health history regarding medications the patient takes should vigilant the dentist to a possible seizure disorder represented in tables 4 and 6.

Table 4. Showing the points to consider for the treatment [23]

Take complete health history

List medications patient is taking

Look them up so you know their drug interaction. and any specific oral effects.Schedule proper frequency of oral hygiene and provide good oral' healthy periodontal tissue and team

Insure proper dental lighting (no light directly in eyes)

Insure mediations have been taken property relative to dental appointments to minimizerisk of  seizure

Perform  proper periodontal and surgical treatment of ginglva! Hyperplasia to minimize damage to teeth and supporting structures and to maintain proper aesthetics.

treatment plan and design restorations to minimize risk of damaging or displacing dental restorations or  prothesis during an epileptic seizure

 Parents  should be made aware of loca! and national resources for information and support relative to their disease.   They should contact the Epilepsy Foundation a! t-800-EFA-1000 or visit their website at www.epilepsyfoundation.org

Table 5. Steps to minimize risk of injury during Epileptic seizures [24]

The chair should be placed in a supine position

If patient has a turn the patient to their left side in order to minimize aspiration foreign bodies or secretions

Use passive restraint only to prevent injury that may occur by the patient hits nearby objects or to prevent them from falling out of the chair

Use passive restraint only to prevent injury that may occur by the patient hits nearby objects or to prevent them from falling out of the chair

Table 6. Characteristics of the seizures that need emergency and medical help depicted [25]

A seizure that continues more than 5 minutes without the patient gaining consciouness between attacks (status epilepticus)

Breathing difficulties after a seizure

Persistent confusion or unconsciousness for more than 5 minutes.

Injuries sustained during a seizure

Conclusion

Dentists with a thorough knowledge of seizure disorders and the medications used to treat them can provide necessary dental and oral health care to these patients. A good health history to fully understand the patient’s disease and the medications they are taking is essential.

References

  1. Annegers JF (1996) The epidemiology of epilepsy. The treatment of epilepsy: Principles and Practice, 2nd ed. Baltimore: Williams & Wilkins, 165-172.
  2. Karolyhazy K, Kovacs E, Kivovics P, Fejerdy P, Arányi Z (2003) Dental status and oral health of patients with epilepsy: An epidemiologic study. Epilepsia 44: 1103-1108. [Crossref]
  3. Devinsky O (2002) Epilpsy patient and family guide, 2nd ed. Philadelphia: Davis Company, 26-49.
  4. Sridharan R, Murthy BN (1999) Prevalence and pattern of epilepsy in India. Epilepsia 40: 631-636. [Crossref]
  5. Aragon CE, Burneo JG (2007) Understanding the patient with epilepsy and seizures in the dental practice. J Can Dent Assoc 73: 71-76. [Crossref]
  6. Devinsky O, Pacia S (1993) Epilepsy 1: Diagnosis and treatment. Epilepsy surgery. Neurol Clin 11: 951-971.
  7. Sirven JI (2002) Classifying seizures and epilepsy: a synopsis. Seminars in Neurology 22: 237-246.
  8. Proposal for revised clinical and electroencephalographic classification of epileptic seizures (1981) Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 22: 489-501.
  9. Proposal for revised classification of epilepsies and epileptic syndromes (1989) Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 30: 389-399.
  10. Greenwood M, Meechan JG (2003) General medicine and surgery for dental practitioners. Part 4: Neurological disorders. Br Dent J 19: 19-25. [Crossref]
  11. Bryan RB, Sullivan SM (2006) Management of Dental Patients with Seizure Disorders. Den Clin North Am 50: 607-623. [Crossref]
  12. Greenwood M, Meechan JG (2003) General medicine and surgery for dental practitioners. Part 4: Neurological disorders. Br Dent J 195: 19-25. [Crossref]
  13. Fiske J, Boyle C (2002) Epilepsy and oral care. Dent Update 29: 180-187.
  14. Stoopler ET, Sollecito TP, Greenberg MS (2003) Seizure disorders: Update of medical and dental considerations. Gen Dent 51: 361-366. [Crossref]
  15. Vorkas CK, Gopinathan MK, Singh A, Devinsky O, Lin LM, Rosenberg PA (2008) Epilepsy and dental procedures. A review. N Y State Dent J 74: 39-43. [Crossref]
  16. Peter L Jacobson (2002) Epilepsy and the dental management of the Epileptic. The Jol Of Contemp Dent Pract 9: 2-9.
  17. Jacobsen PL, Eden O (2008) Epilepsy and the dental management of the epileptic patient. J Contemp Dent Pract 9: 54-62.
  18. Sanders BJ (1995) Managing patients who have seizure disorders. Dental and medical issues, J Am Dent Assoc 126: 1641-1645. [Crossref]
  19. Malamed SF (1997) Handbook of Local Anesthesia, 4th Edition, Mosby, St Louis, 121.
  20. S. Gallagher, S. Weiss, C. J. Oram, T. Humphries, K. E. Harman, S. Menascu (2006) Efficacy of Very High Dose Steroid Treatment in a Case of Landau-Kleffner Syndrome. Developmental Medicine & Child Neurology 48: 766-769. [Crossref]
  21. Tan, H., Gurbuz, T., Dagsuyu, IM (2004) Gingival enlargement in children treated with antiepileptics. J Child Neurol 19: 958-963. [Crossref]
  22. Angelopoulos AP (1975) Diphenylhydantoin gingival hyperplasia. A clinicopathological review. Incidence, clinical features and histopathology. Dent J 41: 103-106. [Crossref]
  23. Mattson RH, Gidal BE (2004) Fractures, epilepsy, and antiepileptic drugs. Epilepsy Behav 5(Suppl 2): S36-40.
  24. A. H. Friedlander, J. L. Cummings (1989) Temporal Lobe Epilepsy: Its Association with Psychiatric Impairment and Appropriate Dental Management. Oral Surgery, Oral Medicine, Oral Pathology 68: 288-292.
  25. D. Buck, G. A. Baker, A. Jacoby, D. F. Smith, D. W. Chadwick (1997) Patients’ Experiences of Injury as a Result of Epilepsy. Epilepsia 38: 439-444.

Editorial Information

Founding Editor-in-Chief

Shigeru Watanabe
Meikai University Japan

Editor-in-Chief

Vagner Rodrigues
Federal University of Minas Gerais

Article Type

Research Article

Publication history

Received: July 01, 2020
Accepted: July 21, 2020
Published: July 24, 2020

Copyright

©2020 Nirmala SVSG. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Nirmala SVSG, Degala S (2020) Dental concerns and management of children with epilepsy: An overview. Dent Oral Maxillofac Res 6: DOI: 10.15761/DOMR.1000356

Corresponding author

SVSG. Nirmala MDS

Professor, Department of Paedodontics & Preventive Dentistry, Narayana Dental College & Hospital, Nellore – 524003, Andhra Pradesh, India

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Table 1. showing classification of Epilepsy

1.

localization related (focal,partial)

Idiopathic

Benign childhood epilepsy with centrotemporal spikes

Childhood epilepsy with occipital paroxysms

Primary reading epilepsy

Symptomatic

Temporal lobe epilepsy

Frontal lobe epilepsy

Parietal lobe epilepsy

occipital lobe epilepsy and childhood

2.

Generalised

Idiopathic

Epilepsy with myoclonic astatic seizures

Benign neonatal familial

Childhood absence epilepsy

Juvenile absence epilepsy

Generalised tonic-clonicepilepsy

Symptomatic

Nonspecific etiology

Early myoclonic encephalopathy

Early infantile encephalopathy

Specific syndrome etiology

Congenital malformations

Inborn error of metabolism

3,

Cryptognic

West syndrome

Lennox-kleffner syndrome

Myoclonic absence seizure

Epilepsy with myoclonic astatic seizures

4.

Undermined origin

Neonatal seizures

Landau-Kleffner syndrome

Seizures during sleep with continuous spike wave

5.

Special design

Reflex originated epilepsy

Isolation

Situation related

Table 2. Syndromes associated with Epilepsy [10,11]

1.

Dravet syndrome

2.

West sndrome

3.

Lennox-Gastaut syndrome

4.

Landau-Kleffner syndrome

Table 3. showing oral manifestations

1.

Self-injury due to seizures and surroundings

2.

Traumatic injuries such as avulsion, luxation Dentoalveolar fractures

3.

Dentoalveolar fractures

4.

Facial fractures

5.

Erythematous gingivae

6.

Gingival hyperplasia due to antiepileptic drug

7.

Secondary infection on the fibrous overgrowtl

8.

Gingival hyperplasia induced malocclusion

9

Malodor and poor oral hygiene

10

Cervical lymphadenopathy

Table 4. Showing the points to consider for the treatment [23]

Take complete health history

List medications patient is taking

Look them up so you know their drug interaction. and any specific oral effects.Schedule proper frequency of oral hygiene and provide good oral' healthy periodontal tissue and team

Insure proper dental lighting (no light directly in eyes)

Insure mediations have been taken property relative to dental appointments to minimizerisk of  seizure

Perform  proper periodontal and surgical treatment of ginglva! Hyperplasia to minimize damage to teeth and supporting structures and to maintain proper aesthetics.

treatment plan and design restorations to minimize risk of damaging or displacing dental restorations or  prothesis during an epileptic seizure

 Parents  should be made aware of loca! and national resources for information and support relative to their disease.   They should contact the Epilepsy Foundation a! t-800-EFA-1000 or visit their website at www.epilepsyfoundation.org

Table 5. Steps to minimize risk of injury during Epileptic seizures [24]

The chair should be placed in a supine position

If patient has a turn the patient to their left side in order to minimize aspiration foreign bodies or secretions

Use passive restraint only to prevent injury that may occur by the patient hits nearby objects or to prevent them from falling out of the chair

Use passive restraint only to prevent injury that may occur by the patient hits nearby objects or to prevent them from falling out of the chair

Table 6. Characteristics of the seizures that need emergency and medical help depicted [25]

A seizure that continues more than 5 minutes without the patient gaining consciouness between attacks (status epilepticus)

Breathing difficulties after a seizure

Persistent confusion or unconsciousness for more than 5 minutes.

Injuries sustained during a seizure