1.2 Epilepsy

Section I: Clinical Scenario and Dental Considerations

Clinical Scenario

A 17‐year‐old female presents to an emergency hospital department following facial trauma experienced during an epileptic seizure (Figure 1.2.1). She complains of pain and mobility in the maxillary central incisors. Your dental opinion is sought.

Medical History

  • Refractory epilepsy (3–5 seizures a day with variable presentation, including generalised tonic–clonic seizures). The patient is awaiting assessment for inserting a vagus nerve stimulator
  • Delayed psychomotor development
  • Intellectual disability (moderate)


  • Ethosuximide
  • Lamotrigine
  • Clonazepam
  • Sodium valproate

Dental History

  • Seizures resulting in repeated trauma in the orofacial region – deciduous and permanent dentition affected
  • Limited co‐operation – only dental examinations possible in the past; no previous dental radiographs or dental treatment undertaken
  • Patient brushes her teeth twice a day, supervised by her mother

Social History

  • Lives with her parents and a younger sibling
  • During the day, the patient attends an occupational therapy centre
  • Patient requires help for basic activities of daily life

Oral Examination

  • Mucosal scarring from previous seizure‐related trauma
  • Displacement, proclination and significant mobility of the maxillary central incisors (Figure 1.2.2)
  • Localised areas of gingival enlargement

Radiological Examination

  • Not performed due to lack of co‐operation

Structured Learning

  1. The decision was made to undertake a detailed examination and deliver any required dental treatment under general anaesthesia in a hospital setting. Why?
    • The patient’s epilepsy is not under control
    • The patient’s degree of co‐operation is limited due to intellectual impairment
  2. What factors are important to consider when assessing the risk of managing this patient?
    • Social
      • Availability of escorts/family to accompany the patient (younger sibling requires supervision)
      • Capacity assessment required: if the patient is assessed as lacking capacity in relation to the proposed procedure, a best interest decision will be required; this should involve family members, social services, any health and social care professionals involved with the adult’s care, carers
      • Deprivation of Liberty standards cannot be applied if the patient is admitted as she is below the age of 18 years old
      • Financial means (insurance coverage) to cover the costs of treatment in a hospital setting under general anaesthesia (varies between countries)
    • Medical
      • Increased risks in general associated with general anaesthesia
        Photo depicts a patient with uncontrolled epilepsy wearing a protective headgear (S).

        Figure 1.2.1 Patient with uncontrolled epilepsy wearing a protective headgear.

        Photo depicts severe displacement of the maxillary central incisors following facial trauma (S).

        Figure 1.2.2 Severe displacement of the maxillary central incisors following facial trauma.

      • High risk of seizures perioperatively due to the refractory epilepsy; hence inpatient bed and neurology support needed during admission
    • Dental
      • Urgency of dental treatment (due to pain/mobility of anterior teeth) – cannot be delayed until the patient may be more stable after the vagus nerve stimulator is placed
      • High risk of further dental trauma
      • Risk of caries related to the oral dryness induced by the anticonvulsant drugs
      • Limited efficacy of brushing exacerbated due to the gingival enlargement (secondary to ethosuximide, sodium valproate, lamotrigine)
      • Potential bleeding tendency (sodium valproate)
      • Difficulty following up the patient due to her lack of co‐operation
  3. You determine that it is likely the displaced incisors will need extraction. Why is a full blood count and coagulation test advisable prior to this?
    • Routine preoperative full blood count testing for patients undergoing general anaesthesia is mandatory in most countries
    • The patient is taking sodium valproate: this can cause blood dyscrasias, including thrombocytopenia, aplastic anaemia, pure red cell aplasia, macrocytosis, neutropenia, and bleeding disorders (coagulation defects)
  4. During the best interest discussion, the patient’s family insists that prosthetic rehabilitation is performed during the same general anaesthetic session as any dental extractions. Why is this not recommended?
    • There is a high risk of dental prosthetic fracture due to further trauma
    • It is advisable to delay this procedure until the epilepsy is controlled (at least wait until the efficacy of the vagus nerve stimulator has been observed)
    • It is also preferable to wait until the remodelling of the bone crest is complete and to rule out damage of the contiguous teeth
  5. During the intraoperative examination, a comminuted fracture of the external table of the maxillary bone is discovered. What is the ideal approach?
    • Attempt to preserve the alveolus and maintain the integrity of the bone crest
    • Consider applying bone regeneration techniques (with bone or filling biomaterials and barrier membranes) (Figure 1.2.3)
    • The risk of delayed healing and exposure of the membrane should be assessed prior to proceeding
  6. What antibiotic should be prescribed after completing the surgical procedure?
    • The recommendation is for beta‐lactams, lincosamides and macrolides
    • Metronidazole and quinolones should be avoided (risk of triggering seizures)

General Dental Considerations

Oral/Perioral Findings

  • As the result of trauma during seizures
    Photos depict (a) Tooth extraction and removal of maxillary bone fragments (S). (b) Bone regeneration techniques application (S).

    Figure 1.2.3 (a) Tooth extraction and removal of maxillary bone fragments. (b) Bone regeneration techniques application.

    • Facial trauma (Figure 1.2.4a)
    • Tooth fractures, luxation or avulsion (Figure 1.2.4b)
    • Temporomandibular joint subluxation
    • Lacerations of the tongue or oral mucosa
  • Adverse effects of antiepileptic drugs
    • Gingival enlargement (phenytoin, sodium valproate, phenobarbitone, vigabatrin, primidone, mephenytoin and ethosuximide) (Figure 1.2.5)
    • Ulcers (carbamazepine)
    • Petechiae and gingival bleeding (carbamazepine, phenytoin and valproate)
    • Xerostomia (carbamazepine)
    • Dental abscesses (phenytoin, carbamazepine and valproate)
    • Delayed healing (phenytoin, carbamazepine and valproate)
    • Rashes (lamotrigine)
    • Hyperpigmentation (phenytoin)
      Photos depict (a) Sequelae of repeated facial injuries secondary to epileptic seizures (S). (b) Tooth intrusion as a result of oral trauma during a seizure (S).

      Figure 1.2.4 (a) Sequelae of repeated facial injuries secondary to epileptic seizures. (b) Tooth intrusion as a result of oral trauma during a seizure.

    • Stevens–Johnson syndrome (carbamazepine, lamotrigine)

Dental Management

  • As with many other neurological diseases, the dental treatment plan will be determined more by the degree of disease control than by the type of disease (Table 1.2.1
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Nov 6, 2022 | Posted by in Implantology | Comments Off on Epilepsy

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