**3. Diagnosis and treatment**

#### **3.1 Diagnosis**

158 Novel Aspects on Epilepsy

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

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

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

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

It is produced by injury to the brain. Seizures are clonic in nature. Muscles involved are the

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

ones most specialized for voluntary movements in the hand, face and tongue.

Petit mal seizures Psychomotor seizures

**2.1 Grand mal seizures** 

**2.2 Petit mal seizures** 

muscles. They may also go unnoticed.

**2.4 Focal seizure (Jacksonian seizures)** 

**2.3 Psychomotor seizures** 

**2.5 Self induced seizures** 

consultation is indicated.

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

the jaw muscles. Micturition and defecation may occur.

may be necessary. Recovery may be quick or patient may be irritable.

normal sleep or activity. No tonic or clonic movements present.

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 important in making a correct diagnosis.

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

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 exclusion of all other causes (Hupp, 2001).

#### **3.2 Treatment**

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

Epilepsy and Oral Health 161

understanding the importance of oral hygiene is difficult for them, which results in the progression of dental caries as well as inflammatory disease of the periodontium (Mann et al., 1984). Patients living with epilepsy have special needs during dental treatment. In almost all aspects of oral health and dental status, the condition of patients with epilepsy is significantly worse than age-matched groups in the general (nonepileptic) population (Karolyhazy et al., 2003). Furthermore, patients who have poorly controlled epilepsy and experience frequent generalized tonic–clonic seizures exhibit worse oral health in comparison with patients who are better controlled or only have seizures that do not

The number of decayed and missing teeth, the degree of abrasion and periodontal indexes are significantly worse in patients with epilepsy. Those with epilepsy also have significantly fewer restored and replaced teeth than the general population (Karolyhazy et al., 2005).

Dentofacial trauma occurring during seizures has been reported to include injuries to the tongue, buccal mucosa, facial fractures, avulsion, luxation or fractures of teeth, and

Generalized tonic–clonic seizures often cause minor oral injuries, such as tongue biting, (Pick & Bauer, 2001) but also frequently lead to tooth injuries (Buck et al., 1997), and in some

Fig. 1. Severe gingival enlargement in a child with epilepsy.

involve the masticatory apparatus (Karolyhazy, et al., 2003).

subluxation of the temporomandibular joint (Ogunbodede et al., 1998).

**4.2 Dental status and oral health** 

cases to maxillofacial trauma (Aragon et al., 2001).

**4.2.1 Trauma** 


changes captured by video and the focal epileptiform abnormalities in the EEG are the most important pieces of information in the presurgical evaluation.

Table 1. Adverse effects of antiepileptic drugs commonly used in children.

Temporal lobectomy is perhaps the most common type of surgery for epilepsy. In the only randomized controlled trial of surgery versus medical treatment, the success rate was 64%. However, patients can experience a significant decline in verbal memory (McKhann et al., 2002). Which can be partly predicted through a detailed neuropsychologic evaluation (Loring, 1997).
