**5. Dental management**

Understanding of epilepsy and seizures raises awareness of the disorder's impact on patients' general medical and psychological health. Dental treatment of patients with epilepsy and seizures should be carried out by dentists who are knowledgeable about these disorders (Aragon & Burneo, 2007). The medical literature contains little information on the influence of epilepsy in dental care.

Patients who have epilepsy have been shown to have significantly worse dental condition than the general population (Karolyhazy, et al., 2003). The disease may affect the dental status and oral health of patients in several ways. Patients who have seizure disorders tend to have less'than ideal oral health, with higher numbers of decayed and missing teeth. They tend to receive less dental treatment, with significantly fewer restored and replaced teeth

Epilepsy is a chronic disease that can affect oral health and prosthodontic status in different ways. However, epilepsy is a condition of various etiologies and seizure types, and different

In a recent analysis of the prosthodontic status of patients with epilepsy, it was found out that compared with age-matched controls, patients with epilepsy have a tendency to become edentulous earlier. It was also found that prosthodontic treatment is suboptimal, as significantly fewer teeth are replaced, despite the fact that epileptic patients tend to have more missing teeth. Based on these findings, the authors suggested a classification for patients with epilepsy according to dental risk factors and dental manageability and

Friedlander and Cummings (Friedlander & Cummings, 1989) mentioned that in patients with epilepsy replacement of missing teeth is important to prevent the tongue from being

Specific guidelines were also provided, such as discouragement of incisal restorations, use of fixed rather than removable prostheses and inclusion of additional abutments if fixed partial dentures are to be used (Karolyhazy, et al., 2005). In addition, the use of metal base for complete dentures and telescopic retention with denture bases made of metal or reinforced with metal for nearly edentulous patients was recommended for those with frequent partial seizures involving the masticatory apparatus, frequent generalized tonic– clonic seizures and other seizures associated with falls. Patients with epilepsy have an increased risk for loosing teeth, and the prosthodontic status of epilepsy patients is not

Anti-epileptic drugs related to oral findings include recurrent aphthous-like ulcerations, gingival bleeding, hypercementosis, root shortening, anomalous tooth development,

Of particular interest to the orthodontist is a recent report of facial and body asymmetries affecting 41% of patients with partial seizures in the population studied; asymmetries

Gingival enlargement may cause delays in permanent teeth eruption and malocclusions in children with mixed dentition (Fig. 2). The hypertonicity of the oral musculature has caused

Understanding of epilepsy and seizures raises awareness of the disorder's impact on patients' general medical and psychological health. Dental treatment of patients with epilepsy and seizures should be carried out by dentists who are knowledgeable about these disorders (Aragon & Burneo, 2007). The medical literature contains little information on the

Patients who have epilepsy have been shown to have significantly worse dental condition than the general population (Karolyhazy, et al., 2003). The disease may affect the dental status and oral health of patients in several ways. Patients who have seizure disorders tend to have less'than ideal oral health, with higher numbers of decayed and missing teeth. They tend to receive less dental treatment, with significantly fewer restored and replaced teeth

the protrusion of the anterior teeth and the orthopaedic compression of the maxilla.

patients may have differing needs in prosthodontic care (Karolyhazy, et al., 2005).

provided recommendations for dental treatment (Aragon & Burneo, 2007).

delayed eruption, and cervical lymphadenopathy (Johnstone et al., 1999).

included both hemihypertrophy and atrophy (Fong et al., 2003).

caught in the edentulous spaces during seizures.

optimal. This may unfavorably affect quality of life.

**4.2.4 Orthodontic problems** 

**5. Dental management** 

influence of epilepsy in dental care.

**4.2.3 Prosthodontic problems** 

Fig. 2. Tooth eruption problem in a child with epilepsy.

than the general population. This situation can be especially true in patients who have development disabilities, who may have trouble accessing dental care anyway. The seizures themselves can cause injuries to the teeth and dental prostheses. Some of the drugs can cause periodontal disease. Specific considerationsfor epileptic patients include the treatment of oral soft tissue side effects of medications and damage to the hard and soft tissue of the orofacial region secondary to seizure trauma, especially in patients who suffer from poorly controlled generalized tonic-clonic seizures (Robbins, 2009).

Dentists with a thorough knowledge of seizure disorders and the medications used to treat them can provide necessary dental and oral health care for those patients. Patients with seizure disorders may report a history of fainting or dizzy spells, seizures, or epilepsy, as well as medications to treat the seizures. A thorough evaluation of a patient's seizure disorder is necessary before initiation of any dental treatment. Important aspects to evaluate include the type of seizures, any known cause, frequency, duration, known triggers such as stress or bright lights, presence of aura before seizure activity, and history of injuries related to effects or drug interactions noted. The drug history can give some indication as to the degree of seizure seizures. Drug history should be carefully reviewed and updated at each visit, and any potential drug side severity or control (Robbins, 2009). The general goal of dental management is the avoidance of a seizure. It is important to know the type of epilepsy and any precipitating factors, medications and dosage, compliance and degree of seizure control before commencing treatment. In addition, drug interactions with anticonvulsants are common and their half-life and blood levels can be increased substantially. Consultation with the child's neurologist is essential before commencement of treatment (Cameron & Widmer, 2008). Unfortunately, even if the patient has been compliant with the

Epilepsy and Oral Health 167

the interdental papillae and a firm, resilient feel, often without inflammation. Local irritants make the response more exuberant in some patients, with the typical erythema, edema, and easy bleeding of common gingivitis. If significant hyperplasia leads to discomfort, inability to function, or esthetic concerns, surgical reduction is necessary. The anterior labial surfaces of the maxillary and mandibular gingiva are the most commonly affected (Fig. 1) and it is strongly correlated with poor plaque control. It is believed that excellent oral hygiene will

Most convulsive disorders are controlled through medication and pose few problems in dental treatment. It should be made sure that the child has taken the daily dose of medicines. Since anxiety is a frequent precipitation factor, premedication with minor

a slightly sedated state due to the CNS depressed activity of anticonvulsant medications. Use of mouth props is mandatory during treatment because once the seizure begins; it is difficult to insert any device to prevent intraoral injury due to clenching of the jaws. If appliances are indicated for tooth movement or tooth replacement purposes, fixed appliance is preferred because there is less chance of dislodgement (Rao, 2008). Generalized tonicclonic seizures often cause minor oral injuries such as tongue biting and tooth injuries. Traumatic injury to anterior teeth should be evaluated in the standard way. Fractures of the anterior teeth can be repaired with composite restorations. A chest radiograph may be indicated if a tooth is avulsed and cannot be accounted for. Soft tissue wounds should be explored for tooth fragments when incisal fractures occur. Patients who have epilepsy can also be at increased risk for maxillofacial fractures caused by drugs-induced osteoporosis

The coarsening of facial features in patients on phenytoin is related to the increased activity of osteoblasts. Other intraoral side effects are seen with anticonvulsant medications, especially in the first few weeks of therapy. A rash or erythema multiforme may develop that can manifest in the mouth as erosions and ulcerations. Phenytoin has been associated with aphthous ulcers. Some of the medications (ie, carbamazepine, phenytoin, phenobarbital) affect bone marrow function, which can lead to altered immune response, thrombocytopenia, and bleeding. Valproic acid inhibits platelet aggregation. Others affect liver function (ethosuximide, carbamazepine), which impairs coagulation. If signs of petechial hemorrhage or abnormal bleeding are noted, hemostasis should be evaluated before surgical treatment. Drug interactions should also be considered for patients on anticonvulsants. A patient taking barbiturates (eg, primidone, phenobarbital) should avoid any other central nervous system depressants such as narcotics or nitrous oxide. Antiepileptic drugs can cause xerostomia, which can put patients at increased risk for developing caries, especially in the cervical region and candidiasis. In children, increased dental caries can also be seen if drugs are delivered in a syrup form. Carbamazepine can cause ulcerations, xerostomia, glossitis, and stomatitis. The frequency of dental check-ups and prophylaxis appointments should be based on the patient's needs. The recall and hygiene interval may be more frequent for epileptic patients because of increased risk for gingival hyperplasia secondary to use of an anti-epileptic drug. Patients who are xerostomic should be put on supplemental topical fluoride to prevent dental decay and monitored regularly for candidal infections. The importance of good oral hygiene should be stressed to the patient and caregivers (if appropriate) (Robbins, 2009). Aspirin carbamazepine increase liver microsomal enzyme activity, decreasing the activity of concurrent, nonsteroidal antiinflammatory medications, and the antifungal fluconazole will increase the blood level of

tranquilizers will be effective. These children often arrive at the dental office in

prevent or reduce the gingival response to phenytoin.

(Turner & Glickman, 2005).

medication, breakthrough seizures can occur. These may be related to fatigue or lack of sleep, menstrual cycle, decreased overall health, a missed meal, alcohol use, physical or emotional stress, or pain. If the patient typically has an aura, it should be noted so that the dentist or staff members can notice any changes and move to protect the patient (Hupp, 2001).

Other conditions can lead to seizures in the dental office. The most common nonepileptic cause is an overdose of local anesthetic. In addition, hypoglycaemia or insulin overdose, hypoxia secondary to syncope, cerebrovascular accident or transient ischemic attack, and hyperventilation can occur in the dental office. If a patient has a convulsive seizure while undergoing dental treatment, stop the procedure and protect the patient from injury. This may involve removing any sharp objects from the area, such as handpieces, placing a soft mouthprop, and cushioning the patient's head. It may also be necessary to control or gently restrain their arms and legs, keep them from falling out of the dental chair, and loosen any tight clothing. As the patient progresses to the postictal phase, maintain the airway because the muscles may become flaccid. Check for level of awareness, reassure them, and determine whether medical assistance is needed. Patients with partial or absence seizures usually are not at significant risk of loss of consciousness; nevertheless, they must be protected from injury. In some patients, the dental staff may be unaware that an episode has even occurred. Status epilepticus of a convulsive seizure must be treated urgently. Intravenous administration of diazepam or midazolam is needed before permanent brain injury occurs. Either drug should be titrated to the point at which seizure activity ceases. Basic life support (ie, airway, breathing, circulation) should be performed as required, and fluid in the mouth should be suctioned from the buccal aspect of the clenched teeth. Nothing should be forced between the teeth at any time, because temporomandibular joint injury or fractured teeth could result. Notification of emergency medical personnel is needed (Hupp, 2001).

It is advisable to check that the patient has taken his/her routine medications, has eaten normally, is not excessively tired, and has not been recently ill before starting dental treatment. Stress and fatigue are factors that can trigger a seizure. If the patient is not feeling well or is overly tired, it may be prudent to reschedule the appointment. Appointments should be scheduled during a time of day when seizures are less likely to occur, if predictable, and stress and anxiety should be minimized. Explaining the dental procedures to the patient before starting, and offering assurance during the procedure may be helpful. The use of nitrous oxide or conscious sedation may be necessary to provide dental care safely and effectively. In patients whose seizure disorder is poorly controlled and whose developmental disabilities make the delivery of dental care difficult, general anesthesia may need to be considered. General anaesthesia is preferable in children with poor seizure control as the abnormal neural activity is completely ablated during the procedure. Dental trauma is an obvious consequence in the child with frequent, poorly controlled seizures. Removable appliances are contraindicated in an epileptic child due to potential airway obstruction (Cameron & Widmer, 2008). Light can be a trigger in inducing an epileptic seizure. Dark glasses used as eye protection and careful positioning of the dental light so that it is directed into the mouth and not flashed in the patient's eyes can minimize any problems (Robbins, 2009).

It is well known that phenytoin causes gingival hyperplasia in a majority of patients. Studies have reported that the drug induces fibroblasts and osteoblasts, that there is an excessive deposition of extracellular matrix, and that normal tissue turnover and wound healing are altered. The most common sites for hyperplasia are the labial aspects of the maxillary and mandibular ridges. The tissue has normal color and surface texture, with lobular shape of

medication, breakthrough seizures can occur. These may be related to fatigue or lack of sleep, menstrual cycle, decreased overall health, a missed meal, alcohol use, physical or emotional stress, or pain. If the patient typically has an aura, it should be noted so that the dentist or staff

Other conditions can lead to seizures in the dental office. The most common nonepileptic cause is an overdose of local anesthetic. In addition, hypoglycaemia or insulin overdose, hypoxia secondary to syncope, cerebrovascular accident or transient ischemic attack, and hyperventilation can occur in the dental office. If a patient has a convulsive seizure while undergoing dental treatment, stop the procedure and protect the patient from injury. This may involve removing any sharp objects from the area, such as handpieces, placing a soft mouthprop, and cushioning the patient's head. It may also be necessary to control or gently restrain their arms and legs, keep them from falling out of the dental chair, and loosen any tight clothing. As the patient progresses to the postictal phase, maintain the airway because the muscles may become flaccid. Check for level of awareness, reassure them, and determine whether medical assistance is needed. Patients with partial or absence seizures usually are not at significant risk of loss of consciousness; nevertheless, they must be protected from injury. In some patients, the dental staff may be unaware that an episode has even occurred. Status epilepticus of a convulsive seizure must be treated urgently. Intravenous administration of diazepam or midazolam is needed before permanent brain injury occurs. Either drug should be titrated to the point at which seizure activity ceases. Basic life support (ie, airway, breathing, circulation) should be performed as required, and fluid in the mouth should be suctioned from the buccal aspect of the clenched teeth. Nothing should be forced between the teeth at any time, because temporomandibular joint injury or fractured teeth could result. Notification of

It is advisable to check that the patient has taken his/her routine medications, has eaten normally, is not excessively tired, and has not been recently ill before starting dental treatment. Stress and fatigue are factors that can trigger a seizure. If the patient is not feeling well or is overly tired, it may be prudent to reschedule the appointment. Appointments should be scheduled during a time of day when seizures are less likely to occur, if predictable, and stress and anxiety should be minimized. Explaining the dental procedures to the patient before starting, and offering assurance during the procedure may be helpful. The use of nitrous oxide or conscious sedation may be necessary to provide dental care safely and effectively. In patients whose seizure disorder is poorly controlled and whose developmental disabilities make the delivery of dental care difficult, general anesthesia may need to be considered. General anaesthesia is preferable in children with poor seizure control as the abnormal neural activity is completely ablated during the procedure. Dental trauma is an obvious consequence in the child with frequent, poorly controlled seizures. Removable appliances are contraindicated in an epileptic child due to potential airway obstruction (Cameron & Widmer, 2008). Light can be a trigger in inducing an epileptic seizure. Dark glasses used as eye protection and careful positioning of the dental light so that it is directed into the mouth and not flashed in the patient's eyes can minimize any

It is well known that phenytoin causes gingival hyperplasia in a majority of patients. Studies have reported that the drug induces fibroblasts and osteoblasts, that there is an excessive deposition of extracellular matrix, and that normal tissue turnover and wound healing are altered. The most common sites for hyperplasia are the labial aspects of the maxillary and mandibular ridges. The tissue has normal color and surface texture, with lobular shape of

members can notice any changes and move to protect the patient (Hupp, 2001).

emergency medical personnel is needed (Hupp, 2001).

problems (Robbins, 2009).

the interdental papillae and a firm, resilient feel, often without inflammation. Local irritants make the response more exuberant in some patients, with the typical erythema, edema, and easy bleeding of common gingivitis. If significant hyperplasia leads to discomfort, inability to function, or esthetic concerns, surgical reduction is necessary. The anterior labial surfaces of the maxillary and mandibular gingiva are the most commonly affected (Fig. 1) and it is strongly correlated with poor plaque control. It is believed that excellent oral hygiene will prevent or reduce the gingival response to phenytoin.

Most convulsive disorders are controlled through medication and pose few problems in dental treatment. It should be made sure that the child has taken the daily dose of medicines. Since anxiety is a frequent precipitation factor, premedication with minor tranquilizers will be effective. These children often arrive at the dental office in

a slightly sedated state due to the CNS depressed activity of anticonvulsant medications. Use of mouth props is mandatory during treatment because once the seizure begins; it is difficult to insert any device to prevent intraoral injury due to clenching of the jaws. If appliances are indicated for tooth movement or tooth replacement purposes, fixed appliance is preferred because there is less chance of dislodgement (Rao, 2008). Generalized tonicclonic seizures often cause minor oral injuries such as tongue biting and tooth injuries. Traumatic injury to anterior teeth should be evaluated in the standard way. Fractures of the anterior teeth can be repaired with composite restorations. A chest radiograph may be indicated if a tooth is avulsed and cannot be accounted for. Soft tissue wounds should be explored for tooth fragments when incisal fractures occur. Patients who have epilepsy can also be at increased risk for maxillofacial fractures caused by drugs-induced osteoporosis (Turner & Glickman, 2005).

The coarsening of facial features in patients on phenytoin is related to the increased activity of osteoblasts. Other intraoral side effects are seen with anticonvulsant medications, especially in the first few weeks of therapy. A rash or erythema multiforme may develop that can manifest in the mouth as erosions and ulcerations. Phenytoin has been associated with aphthous ulcers. Some of the medications (ie, carbamazepine, phenytoin, phenobarbital) affect bone marrow function, which can lead to altered immune response, thrombocytopenia, and bleeding. Valproic acid inhibits platelet aggregation. Others affect liver function (ethosuximide, carbamazepine), which impairs coagulation. If signs of petechial hemorrhage or abnormal bleeding are noted, hemostasis should be evaluated before surgical treatment. Drug interactions should also be considered for patients on anticonvulsants. A patient taking barbiturates (eg, primidone, phenobarbital) should avoid any other central nervous system depressants such as narcotics or nitrous oxide. Antiepileptic drugs can cause xerostomia, which can put patients at increased risk for developing caries, especially in the cervical region and candidiasis. In children, increased dental caries can also be seen if drugs are delivered in a syrup form. Carbamazepine can cause ulcerations, xerostomia, glossitis, and stomatitis. The frequency of dental check-ups and prophylaxis appointments should be based on the patient's needs. The recall and hygiene interval may be more frequent for epileptic patients because of increased risk for gingival hyperplasia secondary to use of an anti-epileptic drug. Patients who are xerostomic should be put on supplemental topical fluoride to prevent dental decay and monitored regularly for candidal infections. The importance of good oral hygiene should be stressed to the patient and caregivers (if appropriate) (Robbins, 2009). Aspirin carbamazepine increase liver microsomal enzyme activity, decreasing the activity of concurrent, nonsteroidal antiinflammatory medications, and the antifungal fluconazole will increase the blood level of

Epilepsy and Oral Health 169

orthodontic treatment and suffered laceration of the lip mucosa and luxation of maxillary incisors; the patient's mother believed that the orthodontic appliance prevented incisor avulsion during the seizure. Accepting such risks should be decision of the patient and/or the guardian after careful discussion with the orthodontist. The metal in a fixed orthodontic appliance may distort images obtained by magnetic resonance imaging (MRI). Any metal portions of the orthodontic appliance close to the area being scanned decreases MRI quality. In some patients, an acceptable MRI may be obtained if arch wires and other removable components are removed before the scan; others will require the removal of the entire orthodontic appliance. This author treated one patient who required yearly MRI brain imaging. The patient's orthodontic treatment was impacted in the following way: fixed appliances were placed the day after MRI scan; 12 months into treatment, all appliances were removed; the MRI was obtained, and appliances were replaced. The fixed appliance was removed after 23 months of therapy, just before the next scheduled MRI scan (Sheller, 2004).

It is the responsibility of every dentist to have emergency procedures planned and rehearsed with their office staff on a regular basis. The dentist should reduce stress of the child by behavioral management and conscious sedation techniques. Reduce direct overhead lighting, particularly for the photosensitive form of epilepsy. Avoid seizurepromoting medications such as CNS stimulants and local anaesthetics containing adrenaline (epinephrine). Emergency drugs such as oxygen, intravenous or rectal diazepam (Valium) and intravenous phenobarbital sodium should be readily available. Take a complete health history and a complete seizure history. List all medications, including side effects and potential drug interactions (Gingival hyperplasia and bleeding tendencies in patients taking drug). Minimize risk for damaging or displacing restorations or prostheses during seizure. The dentist should be careful while positioning of dental light and avoide of known precipitating factors. Consider use of mouth prop at the beginning of procedure. If a seizure occurs while a patient is in the dental chair. Firstly, 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). If possible, remove any foreign material from mouth. If possible, turn patient onto his/her side. Passively restrain only to prevent patient from falling out of chair or hitting nearby objects. After the seizure, it is better to discontinue the therapy. If a cavity is already prepared, either temporize or complete the final restoration. Time the seizure (the duration of the event may seem longer than it actually is). After seizure, turn patient to the side to avoid aspiration and examine for traumatic injuries. If seizure last more than 3 minutes or patient become cyanotic. Administer oxygen at a rate of 6–8 L/minute. If the seizure lasts longer than 1 minute or for repeated seizures, administer a 10-mg dose of diazepam intramuscularly (IM) or intravenously (IV), or 2 mg of ativan, IV or IM, or 5 mg of midazolam, IM or IV. Be aware of the possibility of compromised airway or uncontrollable seizure. Also, contact the patient's family, if he or she is alone (Aragon & Burneo, 2007; Rao, 2008; Robbins,

The oral conditions observed demonstrate the need for dentists to follow up and treat these children. In addition, there is an ongoing need to improve the oral hygiene of these

**5.1 Management of the epileptic patient in the dental office** 

2009).

**6. Conclusion** 

phenytoin and add to the platelet effects of valproic acid. Propoxyphene and erythromycin interfere with the metabolism of carbamazepine, which can lead to toxic levels of the anticonvulsant (Hupp, 2001). Thereafter, patients on VPA should be educated on oral hygiene and their oral health should carefully be followed. Gingivectomy is the treatment of choice in case of gingival hyperplasia that usually occurs with phenytoin therapy. They usually tend to reccur. Hence the drug or the dose can be modified upon consultation with the paediatrician.

The presence of a seizure disorder can influence prosthodontic treatment decisions. Missing teeth should be replaced to prevent the tongue from being caught in the edentulous space and injured. Treatment planning considerations must consider fabrication of dental prostheses designed to minimize the risk for displacement of teeth or further damage. Fixed prostheses or implants are preferable to removable appliances because the latter can dislodge during a seizure and cause oral injury or airway obstruction. Large posterior restorations are prone to fracture in someone who may have jaw spasms during a tonicclonic seizure. All-metal units should be considered whenever aesthetically possible, to minimize the chance of porcelain fracture. In the anterior, metal crowns with acrylic or composite facings can be used to facilitate repair as needed. For fixed partial dentures, the use of additional abutments may be advisable for more stability. If removable partial prostheses are unavoidable, they should be constructed with metallic palates and bases instead of acrylic and metal backings to anterior denture teeth (Robbins, 2009).

The danger of injury to the teeth and prostheses during this type of seizure is the highest and should be considered when designing dental prostheses. For occlusal restorations, the use of ceramic inlays is best avoided; complete metal-ceramic crowns are recommended instead. Generally, fixed rather than removable prostheses are preferred. For fixed partial dentures, the use of additional abutments may be advisable for more stability. If removable partial dentures are unavoidable, the dentures should be designed with a large metal base. As more teeth are lost, telescopic retention may be advised with a base made of metal or reinforced with metal. The base of complete dentures should also be metal or reinforced with metal, because an acrylic base may fracture, increasing the risk of aspiration or dislodgement into the esophagus. A small number of patients with epilepsy, primarily those where the disease is associated with inborn or perinatal encephalopathy, have a severe mental handicap that precludes cooperation. In these patients, general anesthesia is usually necessary to perform dental treatment, and prosthodontic rehabilitation is usually not performed. Seizure-related injuries to prostheses are also an issue, but only for those who are refractory to treatment and suffer from frequent generalized tonic-clonic seizures. Therefore, the large majority of patients can and should receive prosthodontic treatment without restrictions. In a smaller portion of patients, however, certain restrictions apply to prevent potentially dangerous seizure-related complications (Karolyhazy, et al., 2005).

Patients with epilepsy and a malocclusion should have a comprehensive orthodontic evaluation. It is important for the orthodontist to be alert to dental or facial trauma that may have previously occurred during seizures. The level of orthodontic intervention must take into account the type of seizure disorder and efficacy of control. History related by the patient should be confirmed during a discussion with the patient's physician. Adverse side effects of drugs and past dental trauma should be researched by the orthodontist and reviewed as part of patient informed consent. Mechanical challenges such as closing interdental spaces in the presence of gingival hypertrophy should be considered when estimating treatment time. One patient did have a tonic-clonic seizure during fixed

phenytoin and add to the platelet effects of valproic acid. Propoxyphene and erythromycin interfere with the metabolism of carbamazepine, which can lead to toxic levels of the anticonvulsant (Hupp, 2001). Thereafter, patients on VPA should be educated on oral hygiene and their oral health should carefully be followed. Gingivectomy is the treatment of choice in case of gingival hyperplasia that usually occurs with phenytoin therapy. They usually tend to reccur. Hence the drug or the dose can be modified upon consultation with

The presence of a seizure disorder can influence prosthodontic treatment decisions. Missing teeth should be replaced to prevent the tongue from being caught in the edentulous space and injured. Treatment planning considerations must consider fabrication of dental prostheses designed to minimize the risk for displacement of teeth or further damage. Fixed prostheses or implants are preferable to removable appliances because the latter can dislodge during a seizure and cause oral injury or airway obstruction. Large posterior restorations are prone to fracture in someone who may have jaw spasms during a tonicclonic seizure. All-metal units should be considered whenever aesthetically possible, to minimize the chance of porcelain fracture. In the anterior, metal crowns with acrylic or composite facings can be used to facilitate repair as needed. For fixed partial dentures, the use of additional abutments may be advisable for more stability. If removable partial prostheses are unavoidable, they should be constructed with metallic palates and bases

The danger of injury to the teeth and prostheses during this type of seizure is the highest and should be considered when designing dental prostheses. For occlusal restorations, the use of ceramic inlays is best avoided; complete metal-ceramic crowns are recommended instead. Generally, fixed rather than removable prostheses are preferred. For fixed partial dentures, the use of additional abutments may be advisable for more stability. If removable partial dentures are unavoidable, the dentures should be designed with a large metal base. As more teeth are lost, telescopic retention may be advised with a base made of metal or reinforced with metal. The base of complete dentures should also be metal or reinforced with metal, because an acrylic base may fracture, increasing the risk of aspiration or dislodgement into the esophagus. A small number of patients with epilepsy, primarily those where the disease is associated with inborn or perinatal encephalopathy, have a severe mental handicap that precludes cooperation. In these patients, general anesthesia is usually necessary to perform dental treatment, and prosthodontic rehabilitation is usually not performed. Seizure-related injuries to prostheses are also an issue, but only for those who are refractory to treatment and suffer from frequent generalized tonic-clonic seizures. Therefore, the large majority of patients can and should receive prosthodontic treatment without restrictions. In a smaller portion of patients, however, certain restrictions apply to prevent potentially dangerous seizure-related complications (Karolyhazy, et al., 2005). Patients with epilepsy and a malocclusion should have a comprehensive orthodontic evaluation. It is important for the orthodontist to be alert to dental or facial trauma that may have previously occurred during seizures. The level of orthodontic intervention must take into account the type of seizure disorder and efficacy of control. History related by the patient should be confirmed during a discussion with the patient's physician. Adverse side effects of drugs and past dental trauma should be researched by the orthodontist and reviewed as part of patient informed consent. Mechanical challenges such as closing interdental spaces in the presence of gingival hypertrophy should be considered when estimating treatment time. One patient did have a tonic-clonic seizure during fixed

instead of acrylic and metal backings to anterior denture teeth (Robbins, 2009).

the paediatrician.

orthodontic treatment and suffered laceration of the lip mucosa and luxation of maxillary incisors; the patient's mother believed that the orthodontic appliance prevented incisor avulsion during the seizure. Accepting such risks should be decision of the patient and/or the guardian after careful discussion with the orthodontist. The metal in a fixed orthodontic appliance may distort images obtained by magnetic resonance imaging (MRI). Any metal portions of the orthodontic appliance close to the area being scanned decreases MRI quality. In some patients, an acceptable MRI may be obtained if arch wires and other removable components are removed before the scan; others will require the removal of the entire orthodontic appliance. This author treated one patient who required yearly MRI brain imaging. The patient's orthodontic treatment was impacted in the following way: fixed appliances were placed the day after MRI scan; 12 months into treatment, all appliances were removed; the MRI was obtained, and appliances were replaced. The fixed appliance was removed after 23 months of therapy, just before the next scheduled MRI scan (Sheller, 2004).

#### **5.1 Management of the epileptic patient in the dental office**

It is the responsibility of every dentist to have emergency procedures planned and rehearsed with their office staff on a regular basis. The dentist should reduce stress of the child by behavioral management and conscious sedation techniques. Reduce direct overhead lighting, particularly for the photosensitive form of epilepsy. Avoid seizurepromoting medications such as CNS stimulants and local anaesthetics containing adrenaline (epinephrine). Emergency drugs such as oxygen, intravenous or rectal diazepam (Valium) and intravenous phenobarbital sodium should be readily available. Take a complete health history and a complete seizure history. List all medications, including side effects and potential drug interactions (Gingival hyperplasia and bleeding tendencies in patients taking drug). Minimize risk for damaging or displacing restorations or prostheses during seizure.

The dentist should be careful while positioning of dental light and avoide of known precipitating factors. Consider use of mouth prop at the beginning of procedure. If a seizure occurs while a patient is in the dental chair. Firstly, 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). If possible, remove any foreign material from mouth. If possible, turn patient onto his/her side. Passively restrain only to prevent patient from falling out of chair or hitting nearby objects. After the seizure, it is better to discontinue the therapy. If a cavity is already prepared, either temporize or complete the final restoration. Time the seizure (the duration of the event may seem longer than it actually is). After seizure, turn patient to the side to avoid aspiration and examine for traumatic injuries. If seizure last more than 3 minutes or patient become cyanotic. Administer oxygen at a rate of 6–8 L/minute. If the seizure lasts longer than 1 minute or for repeated seizures, administer a 10-mg dose of diazepam intramuscularly (IM) or intravenously (IV), or 2 mg of ativan, IV or IM, or 5 mg of midazolam, IM or IV. Be aware of the possibility of compromised airway or uncontrollable seizure. Also, contact the patient's family, if he or she is alone (Aragon & Burneo, 2007; Rao, 2008; Robbins, 2009).

#### **6. Conclusion**

The oral conditions observed demonstrate the need for dentists to follow up and treat these children. In addition, there is an ongoing need to improve the oral hygiene of these

Epilepsy and Oral Health 171

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Hong, H. H. & Trackman, P. C. (2002). *Cytokine regulation of gingival fibroblast lysyl oxidase, collagen, and elastin.* Journal Of Periodontology, Vol.73, No.2, pp.145-152. Hupp, W. S. (2001). *Seizure disorders.* Oral Surg Oral Med Oral Pathol Oral Radiol Endod,

Johnstone, S. C.; Barnard, K. M. & Harrison, V. E. (1999). *Recognizing and caring for the* 

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#### **7. References**


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**10** 

*South Africa* 

**Clinical Features of Epilepsy Secondary to** 

**Neurocysticercosis at the Insular Lobe** 

Humberto Foyaca-Sibat and Lourdes de Fátima Ibañez Valdés

Neurocysticercosis is eradicable parasitic zoonoses of the brain if it is manages by public health sector and agricultural sector with the dedicated support of veterinarian doctors. Neurocysticercosis is the only zoonotic infection which has been considered as eradicable by the World Health Assembly. Therefore, we will focus on that, and other parasitic zoonoses causing epilepsy will be discussed in another chapter. In this chapter new aspect about

Like other pathological disorders, early diagnosis and treatment can significantly decrease morbidity and mortality rates of parasitic infections. Diseases that have their origins in infected animals, such as H1N1 influenza or SARS have highlighted the need for a better

The ease and speed of modern travel facilitates the spread of diseases once confined to specific geographic areas, as recently occurred with the widely publicized H1N1 influenza. Animal migration and trade pose a similar threat, as was shown by the outbreaks in the United States of West Nile fever, and monkey-pox, two diseases haven't previously known in the Western Hemisphere. Each of these examples highlights the need for accurate, up-todate information and ongoing research on those public health problems. (Carabin, personal

Pig farming has increased considerably during the past decade in Eastern and Southern Africa (ESA); especially in rural, resource-poor, smallholder communities where sanitation is poor. Hence, it is highly suspected that the frequency of epilepsy secondary to NC in the region may further increase in the foreseeable future. We see a lot of pigs affected by cysticercosis free of neurological signs but when there is a sign it can indicate the etiology of human's disease. Let us to address it in a better way, for example pigs with NC do not suffer of epilepsy, however presence of cysticercosis of pigs (intermediate host) indicates that NC is the most likely cause of epilepsy of peoples living around, being yet another reason to support that health worker and agriculture worker should work together in this field. In places where there are not clinical health laboratory facilities and CT/MR images or simply patients have not free to these investigations and the prevalence of epilepsy is considerably high we do suggest to confirm diagnosis of cysticercosis on pig's population

insular epilepsy secondary to NC will be introduced as well.

understanding of their origin on an affected animal.

by physical inspection of the tongue (Figure 1).

**1. Introduction 1.1 Background** 

communication, 2010)

*Division of Neurology, Nelson Mandela Academic Hospital,* 

*School of Medicine, Faculty of Health Sciences,* 

 *Walter Sisulu University, Mthatha,* 

