Taskin Gurbuz

*Department of Pedodontics, Faculty of Dentistry, Atatürk University, Erzurum Turkey* 

#### **1. Introduction**

156 Novel Aspects on Epilepsy

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Epilepsy is the most common chronic neurologic disorder in paediatric neurology and the predominant aetiologies are birth injury and congenital abnormalities. Epilepsy has a tendency to recurrent seizures. Most of these will have primary or idiopathic epilepsy (i.e., no underlying cause will be evident), but some will have secondary epilepsy due to a cause such as head injury, meningitis, or birth asphyxia. The international classification of epileptic seizures divides the epilepsies into those that are generalized, where the whole brain is involved, and the partial seizures, where the aberrant activity involves only a part of the brain (Koch & Poulsen, 2009). In infants, birth injuries and congenital defects are the primary causes of epilepsy. Birth injuries, genetic factors, infections, and trauma are major contributing factors in children and adolescents from 2 to 20 years of age. For individuals between 20 and 30 years of age, brain tumors and other structural lesions are the foremost contributing causes. In those older than 50 years of age, cerebral vascular accidents and metastatic tumors are significant causes of seizure activity (Aragon & Burneo, 2007).

Epilepsy is the most common neurological problem of childhood, and its incidence is the highest in the first decade of life, a period during which children begin and complete a critical part of their social and educational development. Epilepsy is a common chronic neurologic disorder that affects 1–3% of the population, and almost 10% of the population will have one or more seizures at some time in their lives (Hauser et al., 1996). The epilepsies form an array of more or less discrete epilepsy syndromes, characterized by age of onset, hereditary factors, seizure types, electroencephalogram (EEG) abnormalities, and prognosis (Roger, 2005).

A seizure is classified as "partial" when the electrical discharge causing it to occur in a specific area of the brain or "generalized" when the discharge affects the entire brain cortex. When there is loss of awareness, seizures are termed complex. The classification of epilepsy is similar. Epilepsy can be partial or generalized. Based on the cause, it can be symptomatic (caused by a developmental malformation), idiopathic (when a genetic condition is responsible) or cryptogenic (when the cause is unknown) (Aragon & Burneo, 2007). Epilepsy is the most common disorder in paediatric neurology and the predominant aetiologies are birth injury and congenital abnormalities.

#### **2. Classification of seizures**

There are five types of epilepsy, they are: Grand mal seizures

Epilepsy and Oral Health 159

The diagnosis of epilepsy requires the presence of recurrent, unprovoked seizures. Patients presenting with seizures should have a general and neurologic examination, looking for other causes of loss of consciousness (eg, cardiac abnormalities, evidence of infection), contributing factors or secondary causes of epilepsy, and focal neurologic signs. Some of the important clinical findings include alterations in consciousness, sensation, motor abilities, and reflexes. Detailed accounts of the seizures from either the patient or eyewitnesses can be

Diagnostic tools, such as electroencephalography (EEG) and magnetic resonance imaging (MRI), are required to classify epilepsy. EEG records waves generated by the brain cortex. These waves have characteristics that allow the differentiation of normal from abnormal electrical discharges and provide information about localization. EEG amplifies the waves

When diagnosing epilepsy, the underlying disease must be identified. The signs and symptoms of the patient before, during, and after the seizure are vital for determining the cause. The patient and any witnesses should be questioned, and a physical examination for trauma, infections, and other conditions should be completed. Electroencephalography studies will often reveal an abnormality, especially when additional stimuli are recorded, such as flashing lights, music or rhythmic sounds, sleep deprivation, or hyperventilation. The use of blood tests, magnetic resonance imaging, or computed tomography may also yield helpful information leading to a diagnosis. Primary epilepsy is often diagnosed by

Seizure disorders are generally more severe in people who have mental retardation. Patients who have developmental disabilities and epilepsy are treated for their seizure type or types and syndrome just like any other person who has epilepsy. Several options exist for the treatment of epileptic seizures, including antiseizure medications, vagal nerve stimulation, ketogenic diet, and surgery. These options are may be used concurrently in the same individual if needed (Robbins, 2009). The choice of medication is related to the type of seizure (Table). In some cases, a trial of anti-seizure medication may be used in a patient with strong evidence of more than one seizure, whereas a patient with a single seizure is usually monitored but not given medication. Long-term therapy using one anticonvulsant medication is most desirable, although some patients need a combination to achieve efficacy with limited toxicity (Hupp, 2001). The most common oral side effect of antiepileptic drugs seen in the dental office is gingival hyperplasia (Fig. 1). Gingival hyperplasia is characterized by unusual growth of the gingival subepithelial connective tissue and epithelium, for unknown reasons; it is reversed once the drug is discontinued. Anticonvulsant drugs such as phenytoin, carbamazepine, valproic acid, and others have been used individually and in combinations. They act to reduce the frequency of seizures, elevate the seizure threshold of the motor cortex, and limit the spread of the excitation from the focus of the seizure (Hupp, 2001). In an epilepsy program, the objective is to find out whether the patient is a surgical candidate by using special tests, such as prolonged monitoring video-electroencephalography (VEEG) and structural MRI. VEEG allows confirmation of epilepsy syndrome and location of the epileptogenic focus. The behavioural

and transfers them to a computer for interpretation (Aragon & Burneo, 2007).

**3. Diagnosis and treatment** 

important in making a correct diagnosis.

exclusion of all other causes (Hupp, 2001).

**3.1 Diagnosis** 

**3.2 Treatment** 

Petit mal seizures Psychomotor seizures Focal seizure (Jacksonian seizures) Self induced seizures (Rao, 2008).

#### **2.1 Grand mal seizures**

Onset is rapid and preceded by momentary aura. Associated with tonic and clonic phases of muscular spasm, patient losses consciousness and becomes pale. Pupils dilate, eyeballs roll upwards or to one side, the face becomes distorted and there is often rapid contraction of the jaw muscles. Micturition and defecation may occur.

Patient may experience cyanosis during the tonic phase (continuous tension or contraction) lasting for 20-40 seconds. Clonic phase (alternating series of contractions and partial relaxation) may last for several minutes. Patient wakes up from seizure with severe headache and in a general state of confusion. A patient who experiences a grand mal seizure in the dental office should be handled conservatively and be put in a position in which he cannot harm himself possibly on the floor away from the dental equipment. If the seizure is prolonged, administration of oxygen may be necessary. A rubber or plastic mouth prop has to be inserted to prevent the patient from biting his tongue. A tongue blade wrapped with gauze and adhesive may be utilized. It is usually sufficient that the dentist wait until the seizure stops and then evaluate him. If the seizure is prolonged, administration of oxygen may be necessary. Recovery may be quick or patient may be irritable.

#### **2.2 Petit mal seizures**

It appears between 3 years of age and puberty. More common in girls. It consists of transient loss of consciousness. It may occur once or twice a month or very frequently at less intervals and lasting for less than 30 seconds. Other features are upward rolling of eyes, moving of the lids, drooling or rhythmic nodding of the head or slight quivering of the trunk and limb muscles. They may also go unnoticed.

#### **2.3 Psychomotor seizures**

They are difficult to recognize and control. Slight aura is manifested as a shrill of cry or an attempt to run for help. Child is often drowsy or sleeps for a short time after the spell. Seizure consists of loss of postural tone. 1-5 minutes of unconsciousness is followed by normal sleep or activity. No tonic or clonic movements present.

#### **2.4 Focal seizure (Jacksonian seizures)**

It is produced by injury to the brain. Seizures are clonic in nature. Muscles involved are the ones most specialized for voluntary movements in the hand, face and tongue.

#### **2.5 Self induced seizures**

It is possible for some children to induce petit mal or grand mal seizures by over breathing, watching a blinking light or by performing some other form of learned behavior. In such cases drug therapy alone is usually unsatisfactory. Patient by doing so tries to draw attention to himself and is usually associated with complex family problems and psychiatric consultation is indicated.
