Chapter 63 The Patient with a Seizure Disorder Discussion
IntroductionYour 16 year old patient uses a service dog to alert him of an impending seizure. During your patient’s dental prophylaxsis appointment today you inadvertently place the dental light in the patient’s eyes. Shortly following this event, the patient’s service dog stands up and starts nudging your patient’s leg. What should you do?Remember: All posts and responses should contain proper grammar, be free of spelling errors, be substantial, and reflect critical thinking.
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DEH2806 Ch63
Chapter 63, the patient with a seizure disorder.
Be familiar with the terms seizure, convulsion, and epilepsy. A seizure is defined as an episode
of disturbed brain functions that disrupts neuronal brain activity. A convulsion has to do with the
muscles, and it’s an involuntary contraction or a series of contractions of the voluntary muscles.
So when a person has recurring pattern of seizures, they are then identified as having epilepsy.
There are all types of seizures. We’re going to go through them in this PowerPoint. And even
though they look different and have different symptoms, they are all caused by the same thing,
which means a sudden change in how the cells of the brain send electrical signals to each other.
In recent years, the classification of seizures has changed. Now there’s three major groups. The
first one is generalized onset seizure. And what occurs there is both sides of the brain, at the
same time, are getting electrical disturbances. A focal onset is starting in one particular side of
the brain or one particular point in one side of the brain, and it can spread to other areas where it
can then spread to become a generalized, but it is first classified as a focal onset seizure.
Focal seizures used to be called partial seizures. The reason I’m giving you the former names in
these slides is on your National Board, I’m not sure how they’re going to be designated, if they’re
shown at all. Focal seizures are broken down into two different types. One is aware and one is
impaired, and as the name designates, a focal onset aware seizure, the person is awake during the
seizure. A focal onset impaired awareness, either the person is confused or somehow their
awareness is affected during that seizure. The focal onset aware seizure used to be called simple
partial seizure. The focal onset impaired awareness used to be called complex partial seizure.
The third major group is unknown, meaning it’s an unknown onset seizure. Why it’s designated
as that is when the beginning of the seizure is not known. That could be because either the
person lives alone and nobody saw it when that happened, or the person could be asleep, for
example. It could be happening at night. Once a seizure is noticed, and it’s confirmed by a
physician and they check into it, that seizure may be given a different diagnosis later, either a
focal seizure or a generalized seizure.
A diagnosis of epilepsy– remember that’s a pattern of seizures– that’s made from clinical signs
and symptoms, the history of the seizures, an EEG which measures brain waves, or a functional
neuroimaging. Neuroimaging is computerized tomography, which is a CT scan. And it’s used for
most adults, and it’s used for children with a first seizure. And even if a scan is normal in a child,
the doctor will follow up to make sure there’s no other problems.
The rest of this PowerPoint is going to discuss the different types of seizures. And under
generalized seizures, tonic clonic seizure is the one that’s the most well known. It’s the one
people associate with seizures. Tonic clonic, it was previously known as a grand mal seizure. It
begins with the stiffening of the limbs, which is the tonic phase, and then that’s followed by the
jerking of the limbs and face, and that’s the clonic phase.
The tonic clonic seizure is the most well known because the symptoms that are displayed– the
clinical symptoms– are the most dramatic. During the tonic phase, breathing may decrease or
cease. If breathing ceases, the person gets a blue tinge to them. Breathing typically returns during
the clonic phase– during the jerking part– but the breathing may be irregular. The clonic phase
usually lasts less than a minute. Some people only experience the tonic or the stiffening phase,
and others experience the clonic or jerking movements, and then some of them will go back and
forth between that clonic and the tonic phase.
Contrary to popular belief, you do not force things into a person’s mouth that is having a seizure.
There’s an old folklore that they’re going to swallow their tongue while they have a seizure. That
is incorrect. You really do not do much with somebody who’s having a tonic clonic seizure.
Usually they’re going to be on the floor. You’re going to put something soft under their head, if
you can. Loosen any tight clothing they may have.
You want to definitely clear the area of any sharp or hard objects. So if that person has that
seizure in your dental chair, you’re going to move the bracket tray out of the way because there
are sharp instruments on it. You do not restrain that person unless their movements are going to
put them in some type of danger.
What you do want to do is roll that person on their side, because there might be secretions that
come out of their mouth, and you don’t want them to inhale those. And you simply want to stay
with that person until the seizure ends. Common sense should tell you not to pour any liquids in
that person’s mouth, not to offer them food or drinks or any type of medication while they’re
having a seizure. You can offer those things once they’re fully awake.
If the person doesn’t resume breathing, you’re obviously going to start CPR. You want to be very
reassuring and supportive when a person returns to consciousness, because they are not sure
where they are or exactly what has happened. So you want to be very supportive of that. A
convulsive seizure is not usually a medical emergency unless it lasts longer than five minutes or
right afterwards, they start having a second seizure. If the person is pregnant or somehow
injured, or they’re diabetic or they’re not breathing properly, then you’re going to call 911 or get
some type of emergency medical treatment.
Status epilepticus is a medical emergency. It’s a life-threatening event that can occur to
somebody, and it is nonstop seizures. You need to call 911 if that occurs. This has been shown
on previous national boards.
The next type of generalized seizure is simply the tonic seizure. So that person is just
experiencing one thing that’s occurring, and that is when the body– the arms and the legs– they
become suddenly stiff for suddenly tense.
Another type of generalized seizure is a clonic seizure. These are very rare, and they most often
occur in babies. When the jerking occurs, it may last for a few seconds up to a minute.
Sometimes it’s very hard to distinguish a clonic seizure from a myoclonic seizure that we’re
going to discuss next.
The next seizure is a myoclonic seizure. It’s very similar to the clonic seizure, except in the
clonic seizure, the jerking can last from a couple of seconds up to a minute, and the myoclonic
seizure is an extremely rapid contraction of the bodily muscles. Occasionally it’s going to involve
one foot or one arm, and when you’re falling asleep, sometimes if you get that sudden jerk
motion, that’s very similar to a myoclonic seizure.
There’s no first aid precaution for somebody who’s having a myoclonic seizure, other than if that
is their first experience with a seizure, they should have that evaluated by a physician. If you go
to this website, there’s what I consider an entertaining video on something known as fainting
goats.
The next generalized seizure is an atonic seizure, and it’s also called a drop attack. And the
reason it’s called that is that when this seizure occurs, there’s an abrupt loss of muscle tone, and a
person may literally fall to the ground. And of course, if that happens, it would be very similar to
what happens to somebody who faints, is you might hit your head or your face or teeth. To avoid
injury, a person that experiences atonic seizures may wear some type of protective headwear.
Absence seizures were previously known as petite mal seizures. The terms petite mal and grand
mal are still commonly used. Again, I’m not sure what they’re going to use on your National
Board. So that’s why I’m giving you the older terms. But with an absence seizure, there’s a lapse
of awareness. The person may stare. And it only lasts a few seconds. They usually don’t have a
warning, and there’s no after effect. Some absence seizures are accompanied by some type of
myoclonic jerking, maybe only of their eyelids or facial muscles.
Absence seizures are seen more commonly in children, and there are some children that can
experience 50 to 100 attacks a day. It has been misdiagnosed before as the child having some
type of learning disability, when actually what they’re having are seizures. Some people that
experience seizures have something known it’s an aura that occurs to them before they have this
seizure. It could be moments before the seizure. It could be hours before the seizure. An aura is
usually different for each person, and it really doesn’t depend on the type of seizure as to what
type of aura they have. I went to college with a girlfriend who used to experience seeing colors
around things before her seizure occurred.
There are various types of drugs that can be taken when a person has seizures. The main thing to
know about that is it does not cure epilepsy. It’s just trying to mitigate the symptoms that are
occurring. There’s a list in here of the generic names and the brand names of anti-epileptic and
anti-seizure drugs. You most likely have covered some or all of these in your pharmacology
class. You don’t need to memorize these for any examination or any quiz. You do need to know
phenytoin though. For some reason, that still shows up on National Boards. And I have some
slides at the end that discuss what occurs to the gingiva when the person takes phenytoin.
The ketogenic diet, it is very successful if used on young children. It’s an Atkins diet type of
philosophy, where the diet is actually very high in fat and low in carbohydrate, and what occurs
is after a starvation period, it induces fat metabolism, which induces the production of ketones.
It’s not really known why it works. But it does work, and it can actually cure seizures in very
young children. The success rate is extremely high.
If a person does not respond to medications, and their epilepsy is so severe that it impairs their
life, surgery may be recommended. There are two basic types of surgeries that can be done on a
person that does not respond to medications when they have epilepsy. The first would be to
remove a section of the brain, and you find where that focal point is for this seizure, and that
section is removed. If that section is critical to the person’s ability to function in life, then they
cannot remove it, then they put the slices in the area without removing the entire section of the
brain.
A noninvasive basically type of surgery is gamma knife radiosurgery, and that has focal beams
that hit the area where the epilepsy, the focal point, is. Another type of treatment is the vagus
nerve stimulation. We have a few patients in the dental clinic that have these implanted. It’s very
similar to how a pacemaker is implanted, and it even looks like a pacemaker. But then you can
see in this picture here that the leads, they stimulate the vagus nerve, and so research has shown
that when the patient has these nerve stimulators, you can use ultrasonic or the Prophy-Jet on
them. It does not interfere, as it does not with a pacemaker, it doesn’t interfere with how this
works.
The responsive neurostimulator system, this is implanted in the person’s brain. This is not in your
textbook. We do have one patient that is in the clinic that actually has this implanted. It’s very
new. And it’s a computerized electrical device implanted in the skull, and it has electrodes that
connect to the focal point of the seizure center. How this works is that the device contains a
seizure detection software, and so brain electrodes, they send out EEG signals, and so when this
computerized software receives that, it sends a charge to try and disrupt the seizure that’s about
to occur.
There are many different types of service dogs, and one type is a seizure dog. Nobody knows
exactly why, but certain dogs can detect when a person is going to have a seizure. So what they
can do is they can warn somebody ahead of time. They might bark. They might have some type
of device that they can tap and let the person know. But it’s very helpful for a person, especially a
child, who has a seizure.
There are no oral changes that epilepsy, in and of itself, produces. There are oral effects if a
person would fall and do some type of facial damage or damage to their mouth or teeth. That
may occur. And there’s also side effects of certain medications.
The next few slides are going to discuss the gingival overgrowth or gingival hyperplasia that
occurs with phenytoin It is not a drug that is used as often as it used to be, but for some reason,
this shows up on National Boards, so that’s why I have these slides in here. The takeaway from
this is that phenytoin in and of itself, does not produce these gingival hyperplasia reactions. It’s
almost always combined with a person’s oral health or lack of oral health.
The tissue in the early clinical features, it’s fibrotic, stippled, and has a cauliflower-like
appearance. In the advanced clinical stage, you can see in this picture– two things you can see-you can see how overgrown that tissue is, and also you can see that that person has not taken care
of their oral hygiene. So when you combine the medication with lack of oral hygiene, you can
end up with an appearance just like this.
There are two basic types of treatment for phenytoin hyperplasia. The first is non-surgical. The
other one would be surgical. Non-surgical would mean the person would change medications,
would be one way to address it. That is done on the physician’s approval, not on a hygienist’s or a
dentist’s approval. Another non-surgical approach would be scaling, scaling and possibly root
planing, along with a very concentrated program of oral hygiene instruction. If that tissue has
become fibrotic, that needs to be removed surgically.
Surgical treatment, that can be done with a scalpel. Most likely is going to be done with a laser
nowadays. Chlorhexidine, which is Peridex that has had some success to prevent the return of
gingival enlargement once the surgery has been done. Of course, it’s up to the dentist to
determine when surgery is needed, and what type of surgery is needed.
So if there is slight gingival overgrowth, usually they’re going to do the non-surgical approach,
which is the scaling, oral hygiene instruction, and a more frequent recall. If there’s moderate
gingival overgrowth, we’re going to do oral hygiene instruction and scaling, and then the
patient’s going to be brought back to see what, if anything, occurred to have reduction in that
tissue. If there wasn’t reduction, there’s consultation with the patient’s physician about changing
medication, and then possibly moving on to surgical removal of tissue. For severe fiber optic
overgrowth, there’s scaling, oral hygiene instruction, and this is basically done to prepare the
person for surgery. Maintenance appointments one, two, or three-month recalls are indicated.
And it depends on the severity of the gingival enlargement.
A person has controlled epilepsy can easily be seen in a dental office setting. Even if they take
medications, they can have breakthrough seizures. Most patients are aware of that, and they will
let you know. You may want to ask them if they have breakthrough seizures. You can give local
anesthetic. However, if you inadvertently give an intravascular injection, you may precipitate a
seizure in somebody who is prone to seizures.
A diagnosis of epilepsy can be a life-changing event for people. It can affect their ability to
drive. It can affect their occupation. If you go to this website here, it’s a very good website that
gives you a lot of information on epilepsy. If you have somebody that you know that has been
diagnosed with it, there is a section in this web page, if you go to Living With Epilepsy, and
there’s a dropdown, and go Driving and Transportation, it lets you know the state laws for
persons that have epilepsy. And this concludes Chapter 63.
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