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)
Medications
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 controlThe 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?SocialAvailability 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, carersDeprivation of Liberty standards cannot be applied if the patient is admitted as she is below the age of 18 years oldFinancial means (insurance coverage) to cover the costs of treatment in a hospital setting under general anaesthesia (varies between countries)MedicalIncreased risks in general associated with general anaesthesiaFigure 1.2.1 Patient with uncontrolled epilepsy wearing a protective headgear.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 admissionDentalUrgency 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 placedHigh risk of further dental traumaRisk of caries related to the oral dryness induced by the anticonvulsant drugsLimited 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 countriesThe 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 traumaIt 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 crestConsider 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 macrolidesMetronidazole and quinolones should be avoided (risk of triggering seizures)
General Dental Considerations
Oral/Perioral Findings
As the result of trauma during seizuresFigure 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 subluxationLacerations of the tongue or oral mucosa
Adverse effects of antiepileptic drugsGingival 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)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)
The dental team should be trained to provide emergency management of epileptic seizures in a