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EPILEPSYPresented by: Dr. lo’ay Al-HammadOral & maxillofacial resident in RMS

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CONTENTSIntroductionTypes of epilepsyPreventionPreparation and ManagementSummaryConclusionReferences

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INTRODUCTION-Terms seizure and epilepsy are not

synonymous!!!! *What Is the Difference Between Epilepsy & Seizures?

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SEIZURES• SEIZURE/ICTUS- “A paroxysmal disorder of

cerebral function characterized by a short attack involving changes in the state of consciousness, motor activity, or sensory phenomena”……

• A seizure (fit) is a convulsion or transient disturbance in consciousness, caused by abnormal cerebral cortical electrical activity

• EPILEPSY- “A chronic brain disorder of various etiologies characterized by recurrent seizures due to excessive neuronal discharge”….. refers to a tendency to recurrent seizures.

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•Epilepsy is a disorder characterized by recurring seizures (also known as “seizure disorder”)

-A seizure is a symptom of epilepsy

-Epilepsy is a clinical, not a laboratory diagnosis.-Epilepsy is a predisposition for recurrent seizures; it affects approximately 1% of the adult population and may reflect underlying brain pathology (injury, tumors or infections).

-A total of 10% of the population suffer at least one seizure in their lifetime, but mainly in childhood when it may be caused by febrile convulsions.

-Epilepsy is more prevalent in the young and in the mentally or physically impaired… Most cases begin between the ages of 5 and 20 years.

The Brain Is the Source of Epilepsy• All brain functions -- including feeling, seeing,

thinking, and moving muscles -- depend on electrical signals passed between nerve cells in the brain

• A seizure occurs when too many nerve cells in the brain “fire” too quickly causing an “electrical storm”

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-Disturbances of nerve cell activity produce symptoms that vary, depending on which part (and how much) of the brain is affected.

- Seizures may produce changes in awareness or sensation, involuntary movements, or other changes in behavior.

-In general, seizures do not indicate epilepsy but may only occur as a result of a temporary medical condition, such as a high fever, hypoglycaemia, alcohol or drug use or withdrawal, or following brain injury.*conclusión: Single seizure, or recurrent seizures due

to correctable or avoidable circumstances, does not necessarily mean epilepsy !!

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*In nearly two-thirds of the cases of epilepsy, a specific underlying cause is not identified (unknown) but some known conditions and events that may lead to epilepsy are:

■ oxygen deprivation (hypoxia)

■ brain infections (e.g. meningitis, encephalitis, cysticercosis or brain abscess)

■ traumatic brain injury or head injury

■ stroke

■ other neurological diseases (e.g. Alzheimer disease)

■ brain tumors

■ certain genetic disorders.

What Causes Epilepsy?

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Different causes of fits prevail at different ages

Types of EpilepsyA. GENERALISED SEIZURES i. Generalised tonic-clonic seizures ii. Absence seizures iii. Myoclonic seizures iv. Atonic seizures v. Infantile seizures (hypsarrhythmia)

Types of EpilepsyB. PARTIAL SEIZURES i. Simple partial seizures ii. Complex partial seizures iii. Secondary generalized seizures

Types of EpilepsyC. UNCLASSIFIED SEIZURES i. Unclassified seizures

ii. Neonatal seizures iii. Infantile spasms

Partial Seizures• Synonymous with focal

• Activity is restricted to discrete areas of cerebral cortex.

• Typically associated with structural abnormalities of the brain

• Consciousness is fully preserved during the seizure (Simple-partial seizure)

• Consciousness is impaired (Complex partial seizure)

• Partial seizure and then spread diffusely throughout the cortex (partial seizure with secondary generalization)

Simple-Partial Seizure• Motor, sensory, autonomic, or psychic

symptoms.

• Without an obvious alteration in consciousness.

• Three additional features

Three features• “Jacksonian march” abnormal motor

movements may begin in a very restricted region, and gradually progress (over seconds to minutes).

• May experience a localized paralesis (todd`s paralysis) minutes to many hours.

• Seizure may continue for hours or days. ”epilepsia partials continua”.

Simple partial seizure . And Aura• Other forms of simple-partial seizures include

those that cause changes in somatic sensation.

• Some patients describe odd internal feelings. (fear, bad smell ..etc)

• When precede a complex-partial or secondarly generalized seizure, these simple partial seizures serve as a warning or aura.

SIMPLE PARTIAL SEIZURES

Complex-Partial Seizures or temporal lobe epilepsy (psychomotor epilepsy)

• Focal seizure activity

• Patient is unable to respond to visual or verbal commands during the seizure and has impaired recollection or awareness of the ictal phase.

• Frequently begin with an aura.

• The start of the ictal phase is often a sudden behaivoral arrest or motionless stare.

• Usually acompained by automatisms. (automatic performance of complex behaviors), …….such as lip-smacking and chewing movements, or facial grimacing; recalled or inappropriate emotions; changes in personality or alertness; sometimes disorientation, confusion and amnesia, or loss of consciousness; and sometimes olfactory (smell) or gustatory (taste) hallucinations or impairments.

• The patient is typically confused following the seizure.(seconds up to an hour).

COMPLEX PARTIAL SEIZURES

Partial Seizures with Secondary Generalization

• Partial seizures can spread to involve both cerebral hemispheres and produce a generalized seizur, usually of the tonic-clonic variety.

• Is often difficult to distinguish from a primarilly generalized tonic-clonic seizure.

• Careful history identifies a preceding aura.

Generalized Seizure.• Arise from both cerebral hemispheres simultaneously

• Practically defined as bilateral clinical and electrographic events without any detectable focal onset.

• *Generalized seizures are the most dramatic but partial seizures are the most common.

• Classified into:1-Absence Seizure (Petit Mal)2-Atypical Absence Seizures3-Generalized, Tonic – Clonic Seizure (Grand Mal)4-Atonic Seizure5-Myoclonic Seizure

Absence Seizures (Petit Mal)• Sudden brief lapses of consciousness without loss of postural control.

• Typically last for only seconds, consiousness returns as suddenly as it was lost.

• No postictal confusion

• Absence seizures are usually accompained by subtle, bilateral motor signs (rapid blinking of the eyelids, chewing movements, or small-amplitude clonic movements of the hands).

• Can occur hundreds of times per day.

• Always begin in childhood (ages 4 to 8) or early adolescence.

• Hyperventilation tends to provoke.

ABSENCE SEIZURES

• Typical Absence seizure are not associated with other neurologic problems and respond well to treatment with specific anticonvulsants.

• 60 – 70 % will have a spontaneous remission during adolescence.

• Atypical Absence Seizures:

– Lapse of consciousness is usually of longer duration.

– Less abrupt in onset and cessation– Accompained by more obvious motor

signs.

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*TONUS- “Neuromuscular dysfunction characterised by sustained contraction and tonicity of all striated muscles*CLONUS- “An abnormality in neuromuscular activity characterized by rapidly alternating muscular contraction and relaxation”*POST-ICTAL PHASE- “A phase of centralised neuronal depression following a clonic seizure in which the subject demonstrates generalised muscular relaxation observable as deep slumber”

*STATUS EPILEPTICUS- “A prolonged repetitive seizure with no recovery between attacks leading to a life-threatening emergency situation”

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Generalized Tonic – Clonic Seizures (Grand Mal)

• The most common seizure type resulting from metabolic derangements……it is usually begins in childhood, or sometimes at about puberty.

• There is a warning (aura), followed by loss of consciousness, tonic and clonic convulsions, then, finally, a variably prolonged recovery.

• The aura may consist of a mood change, irritability, brief hallucination or headache.

• The initial phase of the seizure is usually tonic contraction of muscles throughout the body.

• After 10 to 20 s. The tonic phase of the seizure typically evolves into the clonic phase, produced by the superimposition of periods of muscle relaxion on the tonic muscle contraction.

• The periods of relaxation progressively increase until the end of the ictal phase.

• Usually last no more than 1 min.

*Postictal phase is characterized by:

1) Unresponsiveness2) Muscular flacciditidy 3) Excessive salivation4) Bladder or bowel incontinence

TONIC-CLONIC SEIZURES

-The sufferer falls to the ground and is in danger of injury. Initially, the face becomes pale and the pupils dilate, the head and spine are thrown into extension (opisthotonos), and glottic and respiratory muscle spasm may cause an initial brief cry and cyanosis.

-There may also be incontinence and biting of the tongue or lips.

• Patients gradually regain consciousness over minutes to hours

• Tipically a period of postictal confusion.

• Headache, fatigue, and muscle ache.

TONIC-CLONIC SEIZURES

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*Complications of major convulsions can be trauma, respiratory embarrassment or brain damage…..

*seizures may progress to status epilepticus but most end without mishap.

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*A major fit is so dramatic that it seems to be of longer duration than is in fact the case,…

- but if it lasts more than 5 minutes (by the clock) or starts again after apparently ceasing, the patient must be regarded as being in status epilepticus, which is particularly dangerous

-the mortality rate can be up to 20%. Brain damage may result from cerebral hypoxia, when tonic and clonic phases alternate repeatedly without consciousness being regained and there can also be inhalation of vomit and saliva.

*status epilepticus is a medical emergency because it causes severe hypoxia, and is

potentially fatal.

Atonic Seizure• Sudden loss of postural muscle tone lasting 1 to 2

s.

• Consciousness is briefly impaired

• Usually no postictal confusion

• Very brief seizure may cause only a quick head drop or nodding movement.

• Longer seizure will cause the patient to collapse. (extremelly dangerous)

ATONIC SEIZURE

Myoclonic Seizure.• Sudden and brief muscle contraction that may

involve one part of the body or the entire body.

• Pathologic myoclonus is most commonly seen in association with metabolic disorders, degenerative CNS diseases, or anoxic brain injury.

*Myoclonic seizures may cause just a single jerk or several jerking movements.

*Generally, the seizure is so brief that although the student loses consciousness, he or she may appear conscious

MYCLONIC SEIZURES

1-Neonatal Seizure

• Less than 1 month of age.

• Brief episodes of apnea, eye deviation, eye blinking, or repetitive movements of the arms and legs.

Unclassified Seizures

2-Infantile Spasms (West syndrome) • It is associated with brain development abnormalities,

tuberous sclerosis, and perinatal insults to the brain.

• It affects infants, which by definition is between 30 days to 1 year of life

• Abrupt movements of the head, trunk, or limbs.

• The classic spasm is a sudden flexion of the neck and abdomen with extension of the limbs.

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-Having a single seizure as the result of a high fever (febrile seizure) or head injury does not necessarily mean that a person has epilepsy.

-Only when individuals have had two or more seizures are they considered to have epilepsy, and the diagnosis requires careful review.

-Disorders that may show features resembling seizures include :

1-transient ischaemic attacks2- rage or panic attacks3-any disorder that causes loss of consciousness, tremors or tics.

*Witness accounts are invaluable.

*NOTES:

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PREVENTION• If pt is a known epileptic, make sure he/she has

taken their regular dose of anti-convulsant on the day of appointment.

• Instruct him/her to alert you as the aura of the impending seizure manifests itself.

• Inhalational sedation, based on individualised severity levels.

• Keep life support equipment ready in case of an emergent status epilepticus.

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General management of epilepsy-A physical examination, including a detailed neurological component, is indicated to confirm the diagnosis; it may show focal neurological deficits but often is normal. -CT and MRI are used to screen for cerebral pathology.

-An EEG records brain electrical activity and may aid in the diagnosis, usually confirming the seizures and possibly, in some cases, indicating the location of a lesion.

It displays 3-Hz spike-and-wave activity in primary generalized absence seizures. However, a normal

EEG does not completely rule out a seizure disorder.

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*Tests for the cause may also include:

-a full blood picture

-blood glucose

- liver function tests

- renal function tests

- inflammatory markers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP])

- CSF analysis to exclude infection.

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*Management of epilepsy includes:1- patient education

2- identification and avoidance of precipitating or trigger factors

3- treatment of any identifiable predisposing pathology or disease

4- prophylactic anticonvulsants.

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-Antiepileptic drugs (AEDs) are the treatment modality used for most people (Table 13.31)

Antiepileptic drugs

-they are of two broad groups:

1) GABA or receptor potentiators

2) neuronal inhibitors

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*Therapy is typically started with a single drug, raising doses until the disorder is controlled.

*A second-line drug is then substituted and some 50% will eventually be able to relinquish medication.

-However, most patients with major epilepsy having more than one attack in a year need to be maintained on AEDs.*A second drug should only be given additionally if a single agent in maximal dosage fails to control fits or causes undesirable toxic effects.

Principles of anticonvulsant therapy

*Do not use the anticonvulsant drug used previously without any success.

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-Antiepileptic drugs should be continued during breast-feeding.-Drug treatment should follow the same principles as for non-pregnant patients but plasma levels need to be monitored, as they may fall during the later stages.

*Plasma levels may sometimes need to be monitored, particularly with phenytoin, where small changes in dosage can cause disproportionately large changes in plasma levels and toxic effects. Since treatment of major epilepsy is often lifelong, adverse effects can be a problem

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-Patients with epilepsy who are drowsy from medication should not operate unguarded machinery or drive.

- Epileptics may not drive a motor vehicle until they have been seizure-free for more than 1 year, or over a 3-year period have only had sleep attacks.*AEDs may interact with other drugs (Tables 13.32 and 13.33); some interfere with the oral contraceptives.

-Traditional AEDs in pregnancy, particularly phenytoin, are potentially teratogenic but there is a greater risk to the fetus from uncontrolled epilepsy.-Phenytoin (Epanutin), carbamazepine (Tegretol) and sodium valproate (Epilim) are all known to be teratogenic and can cause fetal anticonvulsant syndrome (FACS), which affects up to 10% of babies born to women taking anticonvulsants during pregnancy.

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*Anomalies reported in FACS include :1-spina bifida

2- cleft palate

3- heart, kidney and limb malformations.

4-The children also usually have distinctive facial features (prominent forehead, broad flattened nasal bridge, thin upper lip, medial deficiency of the eyebrows and infra-orbital grooves)

-these may be particularly apparent in pre-school children but change, becoming more normal as the children mature.

- Anticonvulsant medication is also a risk factor for the development of an autistic spectrum disorder.

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*Valproate depresses platelet numbers and function to produce a bleeding tendency.

*Valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who start taking the medication before age 20, so….

- young female patients taking it should be monitored carefully by a physician. NSAIDs, erythromycin and benzodiazepines are also contraindicated.*Newer-generation AEDs which are not teratogenic, include:■ Gabapentin■ Lamotrigine■ Levetiracetam■ Oxcarbazepine■ Topiramate.

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*Management of epilepsy -With certain types of partial epilepsy, especially when seizures consistently arise from a single area of brain (the ‘seizure focus’) such as the temporal lobe, surgical removal of that focus may be effective in stopping seizures or making them amenable to medical control.-Other supplemental treatments that are sometimes beneficial include a ketogenic diet (a high-fat, low-carbohydrate diet with restricted calories)

-vagus nerve stimulation therapy (VNST): VNST involves the use of an implantable electronic device in the neck to stimulate the vagus nerve intermittently. Little is understood about how vagal nerve stimulation modulates seizure control but about 50% of patients experience a 40% or greater reduction in seizure frequency and severity.

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*Dental aspects-Dental treatment should be carried out in a good phase of epilepsy, when attacks are infrequent.

-Various factors can precipitate attacks

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-Those who have infrequent seizures or who depend on others (such as those with a learning impairment) may fail to take regular medication and thus be poorly controlled.

-When dental treatment is being carried out in a known epileptic:

1- a strong mouth prop should be kept in position

2-the oral cavity kept as free as possible of debris.

3-As much apparatus as possible should be kept away from the area around the patient.

First Aid for Seizures

• Stay calm and track time.

• Do not restrain the person, but help them avoid hazards– Protect head, remove glasses, loosen tight neckwear– Move anything hard or sharp out of the way– Turn person on one side, position mouth to ground

• Check for epilepsy or seizure disorder

• Understand that verbal instructions may not be obeyed

• Stay until person is fully aware and help reorient them

• Call ambulance if seizure lasts more than 5 minutes or if it is unknown whether the person has had prior seizures

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Potentially Dangerous Responses to Seizure

DO NOT• Put anything in the person’s mouth• Try to hold down or restrain the person• Attempt to give oral anti-seizure

medication• Keep the person on their back face up

throughout convulsion

When to Call 911 or Emergency Medical Services

• A convulsive seizure occurs in a person not known to have seizures or lasts more than 5 minutes

• A complex partial seizure lasts more than 5 minutes BEYOND its usual duration for the individual

• Another seizure begins before the person regains consciousness

• Also call if the person:– Is injured or pregnant– Has diabetes/other medical condition – Recovers slowly– Does not resume normal breathing

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*Drugs can be epileptogenic or interfere with anticonvulsants, or can themselves be changed by anticonvulsant therapy and may, therefore, be contraindicated

*Aspirin, azoles and metronidazole can interfere with phenytoin.*Propoxyphene and erythromycin can interfere with carbamazepine.

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*Large doses of lidocaine given intravenously for severe arrhythmias may occasionally cause convulsions……An overenthusiastic casualty officer may therefore blame a dental LA for causing a fit.

*There is no evidence that this can happen, especially as intravenous lidocaine has also been advocated for the control of status epilepticus.

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*CS in epilepsy should be safe. Stress reduction should reduce the chance of a fit.

*Benzodiazepines are anti-epileptogenic, but occasionally fits have been recorded in epileptics undergoing intravenous sedation with midazolam. Flumazenil, however, can be epileptogenic.

-Nitrous oxide can increase the CNS depression in patients on anticonvulsants.-Temporal lobe (psychomotor) epilepsy, in particular, is associated with paranoid and schizophrenic features. Antisocial and psychopathic behavior may then make dental management difficult.

-Acrylic is probably better used for prostheses than porcelain, as it is more resilient.

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*Convulsions may have craniofacial sequelae, especially lacerations, haematomas and fractures.

•Trauma frequently results from:

1) a grand mal attack when the patient falls unconscious

or from

2) the muscle spasm

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*A range of injuries can result:- fractures of the vertebrae or limbs

-Dislocations

- periorbital subcutaneous haematomas in the absence of facial fractures

- injuries to the face from falling (lacerations, haematomas, fractures of the facial skeleton)

- devitalization, sublimations or loss of teeth (a chest radiograph may be required)

- TMJ subluxation

- lacerations or scarring of the tongue, lips or buccal mucosa.

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FEBRILE CONVULSIONS (FEBRILE SEIZURES)-Febrile convulsions are more common than epilepsy, usually affect children

-result from a rise in body temperature commonly caused by infection; they are seen in about 4% of infants or small children-the child typically losing consciousness and shaking. The seizures characteristically last only last a minute or two; some can be as brief as a few seconds*Risk factors include:

1- young age (below 15 months)

2-frequent fevers

3- immediate family members who have a history of febrile seizures.

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*Children who develop high fevers (above 38°C) should therefore be:

-put in a cool environment

-bathed with tepid water

- given paracetamol (acetaminophen) elixir (not aspirin).

-Children under 18 months should be admitted to hospital since the fit may be due to meningitis.

-Severe febrile convulsions can cause brain damage and about 3% of children with febrile convulsions go on in later life to develop epilepsy; most do not.

Management of febrile seizure

*There is no evidence that short febrile seizures cause brain damage…. most are harmless and warrant no

treatment.

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