Epilepsy and seizure disorders

Overview

Board takeaway: Confirm seizure control, usual medication, and the rescue plan; review drug-related bleeding and cytopenias before invasive care.

Prepare for an in-chair seizure and look for anticonvulsant-related gingival overgrowth.

How do Epilepsy and seizure disorders affect dental management?

• Medical stability: coordinate poorly controlled or changing seizures with neurology; defer elective care when medically unstable.
• Setting: choose from medical status, procedure needs, and cooperation. GA is not a treatment for poor seizure control.
• Triggers: Minimize known individual triggers, including missed medication, sleep deprivation, and stress; light precautions matter particularly when photosensitivity is part of the history
• During dental care: Rubber dam, and a mouth prop with floss tied to it; keep the operatory clear
• Local anesthesia: Local anesthetic in the lowest effective dose (toxic levels lower the seizure threshold)
• Appliances and restorations: Prefer fixed over removable appliances; choose restorations resistant to fracture

Which antiseizure medication effects change invasive dental planning for a child with epilepsy?

• Before invasive care: Review medication monitoring and bleeding/infection history. Coordinate whether current CBC/platelets or other tests are needed before invasive care, especially with known or suspected drug-related cytopenias

Exam pearl

What are Epilepsy and seizure disorders?

A brain disorder characterized by a lasting tendency to have recurrent, unprovoked seizures caused by abnormal electrical activity. A seizure is an episode of that activity; a single provoked seizure does not by itself establish epilepsy.

What are the main systemic features of Epilepsy and seizure disorders?

• Diagnosis: Diagnosed after two or more unprovoked seizures more than 24 hours apart, or one with a high recurrence risk
• Provoked seizures: Simple febrile seizures (2–5% of children aged 6 months to 5 years) are provoked and are not epilepsy
• Seizure types: Focal (with or without impaired awareness) versus generalized (absence, atonic, myoclonic, tonic-clonic)
• Treatment: common drugs: levetiracetam, valproate, carbamazepine, phenytoin, lamotrigine; ketogenic diet; VNS
• Comorbidities: Comorbid autism, ADHD, intellectual disability, mood disorders

What oral findings occur in Epilepsy and seizure disorders?

• Phenytoin: drug-induced gingival overgrowth in about half of users
• Valproate: thrombocytopenia and platelet dysfunction, so bleeding after surgery
• Carbamazepine: leukopenia, delayed healing, and possible aplastic anemia
• Trauma: fractured incisors, tongue and lip lacerations
• Caries: Caries risk from medication xerostomia and sugar-based liquid medications

For Epilepsy and seizure disorders, what do you do for a tonic-clonic seizure?

• Rescue limit: Never insert anything in the mouth during a seizure. Floss-secured mouth props are for dental treatment, not seizure rescue.

• Stop and time the seizure. Remove instruments only if safe; do not force the mouth open. Protect the head and prevent falls without restraining movements. Position on the side when safely possible to aid drainage

• Support airway/breathing, oxygen, prescribed rescue medication; insert nothing in the mouth

• CDC first-aid EMS triggers: seizure lasting longer than five minutes, another seizure soon afterward, trouble breathing or waking afterward, injury, or a first seizure. Also call for a seizure in water, pregnancy, or diabetes with loss of consciousness.

• Use the prescribed rescue plan: follow any earlier activation trigger. These are first-aid EMS criteria, not a definition of status epilepticus or a rescue-drug dosing rule.

• Afterward: recovery position; check for oral injuries or lost appliances

When does CDC seizure first aid call for EMS in a child with a seizure?

Call for a seizure lasting longer than five minutes, another seizure soon afterward, trouble breathing or waking afterward, injury, or a first/unknown seizure.

• Other CDC triggers: a seizure in water, pregnancy, or diabetes with loss of consciousness.
• Follow any earlier trigger in the child’s prescribed rescue plan.
• This is first-aid escalation guidance, not a status epilepticus definition or drug-dosing protocol.

For Epilepsy and seizure disorders, what seizure history do you take?

• Pattern: seizure type, frequency, date of the last seizure, and usual duration.
• Recognition: triggers and warning signs.
• Rescue plan: medication and route, such as rectal or intranasal diazepam or intranasal or buccal midazolam.
• Today: whether the child took their usual medication and ate.

For Epilepsy and seizure disorders, how do you treat phenytoin-induced gingival overgrowth?

• Reduce severity: meticulous plaque control and chlorhexidine.
• Gingivectomy: when overgrowth interferes with function or esthetics; accept recurrence.
• Medication review: the neurologist may consider an alternative drug.

Sources

• Supplemental study guide: Pediatric Dental Study Guide: Epilepsy / Seizure
• Definition: MedlinePlus: Epilepsy
• Management of Dental Patients with Special Health Care Needs
• Management of Medical Emergencies
• Supplemental clinical source: CDC: First Aid for Seizures