• a recurrent disorder of cerebral function marked by sudden brief attacks of altered consciousness, motor activity, or sensory phenomena.

• a neurological condition, which affects the nervous system. (epilepsy is also known as a seizure disorder)

• usually diagnosed after a person has had at least two seizures that were not caused by some known medical condition (example: alcohol withdrawal or extremely low blood sugar)

• seizures in epilepsy may be related to a brain injury or a family tendency, but most of the time the cause is unknown.

• the word "epilepsy" does not indicate anything about the cause of the person's seizures, what type they are, or how severe they are

• intermittent muscular contractions and relaxation
• movement during a seizure

• sustained muscular contraction
•  the patient will appear stiff or rigid

• condition in which seizures are so prolonged that recovery does not occur between attacks
• experiences one seizure after another or one very long seizure (a seizure lasting 5+ minutes)
• most dangerous type of seizure
• system is overworked (increased BP & HR) and can result in death (cardiac arrest)

Questions to ask your if they indicate they have seizures

1. What type of seizure do you have?

2. When was your last seizure?

3. Do you know when a seizure is about to happen, do you experience an “aura”?

4. Have you had a seizure during dental TX?

5. Is there anything I should avoid that may precipitate a seizure?

• brief, localized, electrical brain discharges that often precede a serious seizure (but it is still conisdered a part of the actual seizure) 
• examples: wierd taste, smell, numbness, visual and auditory hallucinations
• not everyone has it
• happens seconds to 1 hour before the seizure

• Prevention of injury and maintenance of airway 
• Management of most patients is based on prevention, or minimizing frequency
• Goal accomplished usually through drug therapy (despite therapy, seizure activity may still develop)
• Usually don't need to administer anti convulsant drug because most seizures are self limiting

Who is most susceptible to seizures?

• Children are 50% more likely to experience a seizure

1. Carbamazepine (Tegretol, Carbatrol

2. Phenytoin (Dilantin, Phenytek)

3. Phenobarbital

4. Clonazepam (klonopin)

5. Valproate (depacon)

6. Felbamate (felbatol)

1. Simple partial

2. Complex partial

3. Generalized convulsive (grand mal)

    Generalized non-convulsive/absence (petit mal)

4.  Acquired epilepsy.

1. Head injury                                                       

2. Injury during birth

3. Brain tumor (most common cause & can happen at any age)                                                     

4. Cerebral palsy

5. Drug toxicity (withdrawal from drugs or toxic overdose of drugs)  

* local anesthetic overdose, most likely not an epeleptic seizure in a dental office!                                                   

6. Severe infection

7. High temperature (most common in children)

8. Heredity/congenital abnormalities

• Confined to small area of the brain (1 hemisphere)
• Feels tingling sensation in arm, finger or foot
• Can speak  unintelligibly
• Conscious and alert patients
• "Jerking" movements

• Involves one or both sides of the brain

• Consciousness is altered and pt might not be able to respond

• May progress to a convulsive seizure

• May see flashing lights (not always)

• Perceiving bad odor “aura”

• Associated with complex behavior patterns called automatisms.

   

Automatisms

• small, repetitive non-purposeful actions (locked into mechanism)

• loss of voluntary control
• most often the duration of the confusion takes place as a continuation of whatever behavior was previously occurring (example: smacking lips, pacing room, continued spoon feeding)
• patient usually comes back in 1-3 minutes
• occurs most often with absence or complex partial seizures, or after tonic-clonic seizures.
• because consciousness is lost, individulas are typically not aware that these movements have occured 

• Also called absence seizure
• Loses awareness of what is happening  for 5-30 seconds
• May have a blank stare (daydream look), twitch or blink rapidly
• More common in children 3-15 years old
• Often goes unnoticed or misdiagnosed
• Abrupt onset by complete suppression of all mental function and abrupt termination
• Flashing lights tend to trigger this type of seizure

Prodromal Phase

• several minutes to several hours, patient can exhibit subtle to obvious changes. 
• “aura” can happen in this phase (is evident to somebody who knows the patient well)

• occurs after the “aura”
• the patient loses consciousness
• most seizure related injuries happen during this phase
• heart rate and blood pressure increase (almost double)

• tonic/clonic components involved
• tonic: 10-20 seconds  clonic: 2-5 minutes
• can become cyanotic (blue)
• respiratory distress can occur due to body being so rigid

• breathing becomes normal
• consciousness returns
• can lose bladder and bowel control
• can take up to 2 hours to fully recover

• Seizure of an epileptic patient                
• Hypoglycemia
• Hypoxia secondary to syncope (lack of O2)                 
• Local anesthetic overdose (most likely in dental office)

• History of seizures well controlled by meds (no acute seizures in past 3 months)
• Take usual ASA II considerations
• Yellow Light Patient

• History of seizure activity controlled by meds, yet seizures occur more often than 1 per month
• ASA III considerations (including preparing for seizure management)
• Yellow Light patient

• History of status epilepticus

• Patient needs medical consult before treatment

• No elective dental care

• Yellow Light patient

• History of seizure activity poorly controlled by meds (seizures happen more than once per week)
• Medical consult and better control of seizures before patient can receive routine dental treatment
• Red Light patient

• Prevention of injury and maintenance of airway

• Keep patient in chair, hold them down so they don’t hurt themselves but let the seizure happen

• Place the patient in the supine position

• Remove everything out of their mouth and out of the way (suction if needed)

• Activate EMS if seizure last more than 5 minutes

• Usually don’t need to administer anticonvulsant drug because most seizures are self limiting

• characterized by alterations in consciousness, motor function, and sensory perceptions; usually have a rapid onset and brief duration (usually one to three minutes)

• a sudden surge of electrical activity in the brain that usually affects how a person feels or acts for a short time

• seizures are not a disease in themselves, they are a symptom of many different disorders that can affect the brain

• some seizures can hardly be noticed, while others are totally disabling.

• heightened anxiety and fear of dentistry can lead to exacerbation of medical problems ...
  1. angina
  2. seizures
  3. asthma
  4. hyperventilation
  5. vasodepressor syncope

1. medical history questionnaire
   • patients are more likely to write down thier fears vs. telling you
2. dental anxiety questionnaire
3. observation
   • patients ususally try to hide thier fear of dentist

1. ↑ BP & HR
2. Trembling
3. Excessive sweating
4. Dilated pupils
   • can be difficult to manage
   • might look "on guard"
   • stiff posture & white knuckled in chair
   • talk about how much they hate the dentist
   • may no show appointments frequently

• Overly willing to oblige
• Quick actions
• Nervous looking
• Perspires
• Conscious sedation may work in these patients
• General anesthesia rarely needed
• Useful to discuss fear wtih patients

Generalized Convulsive (Grand Mal)

AKA – Tonic/Clonic seizure

n       Occurs in phases ( Prodromal,  Preictal,  Ictal & Postictal)

n       Slight personality changes

n       May experience “Aura”

n       Tonic stage – body becomes rigid

n       Clonic stage – body jerks violently

n       Foaming at the mouth

n       May lose bowel and bladder control

n       Seizure is over, pt. begins to recover, may not remember what happened, may require sleep to recover.