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human diseases > 24.2 Epilepsy > Flashcards

24.2 Epilepsy Flashcards

1
Q

What are the 3 different diagnostic criteria for epilepsy?

A

1) At least 2 unprovoked seizures occurring more than 24 hours apart
2) One unprovoked seizure with a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures, occurring over the next 10 years
3) Diagnosis of an epilepsy syndrome

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2
Q

What is a seizure?

A

A temporary disruption of brain function due to hypersynchronous, abnormal firing of cortical neurons.
Sudden burst of uncontrolled electrical acitivity in the brain which causes disruption to the pt’s ability to function.

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3
Q

What may cause a seizure?

A
  • Stroke
  • Brain tumour
  • Head injury
  • Infection
  • Metabolic disturbance (high fever, hypoglycaemia, alcohol or drug use or withdrawal)
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4
Q

What are the types of seizures?

A

Focal onset:
- Focal aware (systems depend on area of abnormal acitivity e.g. motor cortex will cause rhythmic movements, sensory regions will cause hallucinations
- Focal impaired awarenss (post-ictal afterwards)

Generalised onset:
- Myoclonic (muscle jerk, may be precusor to tonic-clonic)
- Absence seizure (blank and unresponsive)
- Tonic-clonic
- Atonic (muscles relax, pt floppy) and tonic (stiff and fall)

Unknown onset

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5
Q

Describe a tonic-clonic seizure.

A
  • Tonic phase: epileptic cry, body goes stiff, fall to the floor
  • Clonic phase: clonic jerks of limbs, may become incontinent, breathing may be affected
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6
Q

What seizure type has a high risk of facial/tooth injury?

A

Atonic (generalised onset): also known as drop seizure, pt normally falls

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7
Q

What might a patient have before their seizure?

A

An aura, an awareness/feeling that a seizure is about to occur.

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8
Q

What are the causes of epilepsy?

A
  • Genetic: benign familial neonatal epilepsy, Dravet syndrome
  • Infection: refers to a patient with an epilepsy diagnosis who experiences an infection (e.g. neurocysticercosis, TB, HIV, cerebral malaria, Zika virus). Not referring to people who have a one-off seizure as a consequence of infection e.g. meningitis.
  • Metabolic: e.g. porphyria, uraemia, cerebral folate deficiency
  • Immune: refers to immune disorders in which seizures are a core symptom e.g. autoimmune epilepsy
  • Structural: abnormalities which are visible on structural imaging. May be acquired e.g. stroke, trauma, infection or genetic such as malformations of the brain.
  • Co-morbidities: children with learning disabilities may have epilepsy, psychological problems such as depression, behavioural problems
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9
Q

Name some common epilepsy drugs.

A
  • Sodium valproate
  • Lamotrigine
  • Gabapentin
  • Carbamazepine
  • Oxcarbamazepine
  • Phenytoin
  • Pregablin
  • Clobazam (adjunctive)

Around 50% of pts have their seizures managed with 1 medicine alone.
Around 30% of pts will continue to have seizures when taking multiple medicines.

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10
Q

What treatment options are there for pts who don’t respond to epilepsy medication? (Aka medically refractory epilepsy)

A
  • Surgical resection: removing a small portion of the brain
  • Deep brain stimulation
  • Vagus nerve stimulation
  • Responsive neurostimulation
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11
Q

What are the side effects of sodium valproate?

A
  • Can cause thrombocytopaenia (low platelets) which may cause drug induceed gingival enlargement
  • Can cause liver impairement which affects amounts of LA used
  • Drowsiness
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12
Q

What are the side effects of phenytoin?

A
  • Drug induced gingival enlargement (50% risk)
  • Altered taste
  • Thrombocytopaenia
  • Teratogenic potential
  • Dental anomalies
  • Ulcers
  • Cervical lymphadenopathy
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13
Q

What are the side effects of gabapentin?

A
  • Dry mouth
  • Vomiting
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14
Q

What are the side effects of lamotrigine?

A
  • Dry mouth
  • Vomiting
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15
Q

What are the side effects of carbamazepine?

A
  • Glossitis
  • Ulceration
  • Dry mouth
  • Stomatitis
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16
Q

Describe the association between phenytoin and drug induced gingival enlargement.

A
  • Relationship between levels of phenytoin in plasma and relationship with oral hygiene, more common in patients who are prone to periodontitis already
  • Theory: there is a genetically distinct population of fibroblasts which react to phenytoin and leads to fibroblast accumulation in connective tissue, thus leading to gingival enlargement
  • Reported to resolve spontaneously within 1-6 months following phenytoin withdrawal
  • Can liaise with doctor to prescribe alternative medicine
17
Q

Which drugs may you prescribe as a dentist that can interfere with drugs used to treat epilepsy?

A
  • Metronidazole: can interfere with phenytoin
  • NSAIDs: can increase the bleeding tendency induced by sodium valproate
    -Doxycycline: metabolism may be increased by carbamazepine
  • Azole antifungals: can interfere with phenytoin and carbamazepine, can increase the bleeding tendency induced by sodium valproate
18
Q

What are vagus nerve stimulators?

A
  • For pts with medically refractory seizures
  • Implanted below the left clavicle with a lead that wraps around the left vagus nerve in the carotid sheath
  • Intermittent electrical stimulation reduces the intensity of seizures
  • Number of electrical pulses it gives out is determined by the neurologist
  • Does not completely stop seizures but reduces seizure frequency and the length of time
19
Q

What are the side effects/risks of vagus nerve stimulation?

A
  • Risk of infection during placement
  • Increased risks of obstructive sleep apnoea
  • Dental machines do not interfere with the device
  • Cannot perform monopolar cautery for these pts
  • Placing a magnet over the stimulator turns it off
20
Q

What should you enquire about when taking a history for a patient with epilepsy?

A
  • Ensure you have a record of their full epilepsy diagnosis and a description of the types of seizures they have
  • Frequency of seizures
  • Triggers of seizures e.g. strong smells, bright lights, stress, fatigue, vibration (electric toothbrushes)
  • Do they have an aura? Does it always progress to a seizure?
  • What happens during a seizure? Speed of onset, symptoms, length of seizure, speed of recovery
  • Date of last seizure
  • What medicines are they taking, dose, frequency etc
  • Who manages their epilepsy? Specialist? Multidisciplinary team? Neurologist?
  • Do they have any associated learning disability or communication disorders?
21
Q

What considerations should be made in the dental treatment of patients with epilepsy?

A
  • Ensure anti-epileptic medicines have been takien as normal
  • Limit any potential triggers
  • Ensure you are aware of any auras which may precede seizure and for pt to inform operator
  • Keep LA dose as low as reasonably possible, LA overdose is known to cause seizures
  • Check BNF for interactions when prescribing medicines
  • Emphasise importance of oral hygiene to prevent drug induced gingival enlargement
  • Avoid electric toothbrush if vibrations are a trigger
  • Gingival enlargement may require periodontal specialist management
  • Increased risk of dental and facial trauma from falls
  • Consider design and material choice for removable prostheses e.g. well-fitting, retentive denture, use clasps
  • If pt has a seizure with removable appliance in their mouth it may pose an airway risk, where possible it is best to use fixed prostheses (bridges)
22
Q

Where should epileptic patients be treated?

A
  • Well controlled can be treated by GDP (ASA 2)
  • Poorly controlled usually secondary care (ASA 3/4)
  • May need to liaise with neurology/epilepsy team for pt with vagus nerve stimulator
  • Referral for sedation if pt is particularly anxious
  • Avoid elective care if pt has uncontrolled epilepsy until they are stable
23
Q

What should you do if a patient has a seizure in practice?

A
  • Stop treatment, pt should return at a future date, temporise cut cavity with temp material
  • Remove any equipment from their mouth
  • Lie them flat
  • Do not place anything in their mouth or try to stop them from biting their tongue
  • Monitor the airway
  • Time the seizure
24
Q

When are seizures classed as an emergency in practice?
Known as status epilepticus.

A

Status epilepticus:
- Seizure lasts longer than 5 minutes
- Multiple seizures with short recovery time in between
- More than 3 seizures in an hour

If this happens deliver buccal midazolam and call 999.

25
Q

What risks are associated with status epilepticus?

A
  • Long seizures can cause brain damage
  • High mortality risk of approx. 20%
26
Q

What medication can be given in cases of status epilepticus?

A
  • 10mg buccal midazolam (a benzodiazepine)
  • Place into buccal sulcus
27
Q

Describe non-epileptic attack disorder/dissocaitive seizures.

A

It is a way for people to control excessive stress, such as following traumatic events.

Dissociative disorders happen when people dissociate for long periods of time or regularly which affects their daily life.
- Some people with dissociative disorders experience physical symptoms such as seizures
- These seizures don’t appear to have a physically cause, normal brain function occurs during seizure
- 20% of people diagnosed with epilepsy, when assessed by specialists, are found to actually have non-epileptic seizures

28
Q

What are the features of dissociative seizures?

A

Patient is unconscious
- Convulsions of arms, legs, head or body
- Incontinence
- Tongue biting
- Absence type symptoms

29
Q

What is the management of dissociative seizures?

A
  • Anti-epileptic medicines do not control these seizures
  • Buccal midazolam does not have any effect
  • Psychotherapy is recommended e.g. CBT
  • Anxiety or depression medication may be helpful

Will not enter status epilepticus- the seizure is normally self-limiting.
Reassurance during seizure thought to be helpful.

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