The Patient with a Neurological or Seizure Disorder Baylor College of Dentistry Tammy Fisher RDH BS March 22, 2016

Objectives Upon completion of the classroom presentation and reading assignments, the student will be able to: Explain the etiology of seizure disorder. Describe factors that may precipitate a seizure. Compare and contrast the characteristics of the three common types of seizures…Absence, Tonic-Clonic, Status Epilepticus Recognize the generic and brand names of the drugs of choice used to control seizures and the possible side effects. Etiology is very difficult to pinpoint. Birth trauma, genetic, head injury, metabolic disorders, alcohol, drugs, stroke, fever, infection, brain tumors and chemical imbalances may cause seizures.

Objectives Explain the role of the dental hygienist in the treatment of a patient with seizure disorder. Explain the emergency management of a seizure. Discuss the clinical procedure at Baylor College of Dentistry for management of the patient with a seizure disorder. Medical clearance by the physician!! Define all related terminology for the patient with a seizure disorder.

Definitions Epilepsy-describes a group of functional disorders of the brain Seizure-a paroxysmal event resulting from abnormal brain activity Convulsion-a violent spasm Prodrome-a symptom indicating the onset of a condition, may begin a few days or hours before the onset, headache, irritability, depression, insomnia, bad mood Paroxysmal- a sudden violent attack

Definitions Aura-vague feelings immediately preceding a seizure, there may be unpleasant smells, hallucinations, dream-like visions, feelings of fear Absence-a generalized seizure of sudden onset characterized by a brief period of unconsciousness Tonic-Clonic-(Grand Mal seizures)a sudden sharp tonic contraction of muscles followed by clonic convulsive movements Status Epilepticus-rapid succession of epileptic spasms without intervals of consciousness; life threatening; emergency care urgent; may last from 5 to more than 30 minutes 42,000 deaths per year with Status Epilepticus. A common precipitating factor in adults is noncompliance with medication or withdrawals from medication.

Sudden Unexplained Death in Epilepsy (SUDEP) living with epilepsy and seizures that may increase the risk of early death.  not well understood,  suspected to be related to heart rhythm problems during a seizure. more often among people with convulsive seizures, especially generalized Tonic-Clonic seizures that are not well controlled. Person with seizures dies unexpectedly

Sudden Unexplained Death in Epilepsy (SUDEP) Other risk factors include: Poorly controlled seizures Treatment with multiple anticonvulsant drugs Chronic epilepsy Epilepsy at a young age Generalized Tonic – Clonic seizures Discontinuing or irregular taking of medications

Seizures may be precipitated by: STRESS Fatigue Sleep Deprivation Apprehension and Anxiety Sensory Stimuli Every dental hygiene student!!

4 Stages of a Seizure Prodromal Aura Seizure (Ictus) Post-Ictal Phase

Treatment No known cure Medications first line of therapy for epilepsy – dozens of anti-epileptic medications Drug of choice – should control seizures with no side effects. Most medications do not completely control the condition. Drugs work by making over-active brain cells less excitable. Others drugs work by decreasing the brain cells’ ability to transmit abnormal impulses. Do not stop meds abruptly – cause seizure Other treatment include: Vagus Nerve Stimulation Therapy(only for uncontrolled cases over age 12), Medical Marijuana and the Ketogenic Diet Ketogenic diet- high fat, moderate protein and low carb. Vagus nerve stimulation reduces seizures by ½ for 1/3 of patients who receive the treatment, 1/3 see some reduction and 1/3 see no reduction. Medical marijuana does relieve some seizure activity in the 1/3 that do not respond to other treatment, Tx passed a law in 2015 to allow a cannibis oil for intractable seizures but did not allow a broad use of medical marijuana.

Advanced Gingival Hyperplasia Lobules Cleft-like grooves Increased size of marginal gingiva Maxillary anterior – usually affected

Seizure Characteristics Unprovoked Unpredictable Involuntary Uncontrollable length Sudden paroxysmal electrical discharge of neurons in the brain

What to do: #1 Do not panic! Call for help Terminate treatment Position patient to supine position and monitor safety Push away any movable equipment

What to do: Do not place ANYTHING in the mouth! Place patient on their side Stay with the patient If seizure reoccurs or is still continuing in five minutes, call 911 Document!

https://www.youtube.com/watch?v=4qWPFCFmRlI

Emergency procedures Stop all treatment Try to keep patient calm. Do not restrict movement If seizure continues for more than 5 minutes call 911 Turn patient on side Prompt treatment is key to preventing death Hospital treatment consists of IV drugs such as diazepam, lorazepam, phenytoin and phenobarbital.

Commonly Prescribed Medications Keppra Lyrica Neurontin Tegretol Topamax Clonazepam Phenobarbital Phenytoin Gabapentin

Jigsaw Exercise 30 Students will number off from 1-6, and move into 6 groups. Then they will number off from 1-5 and pick up a numbered envelope according to their number. All the 1’s will gather with envelope #1, and so on. The students will have 10 minutes to research the questions with their group. Then they will return to their original group and teach those classmates the part they learned for 10 minutes. Group 1- clinical manifestations Group 2- treatment other than medications Group 3- common medications Group 4- oral findings Group 5- dental hygiene care plan

Closing Wrap up Two minute free write

References Darby, M. 2014. Dental hygiene theory and practice (pp. 881-883). St. Louis, MO: Saunders/Elsevier Wilkins, E. M. 2013. The patient with a seizure disorder. In Clinical practice of the dental hygienist (pp. 940-951). Philadelphia, PA: Lippincott, Williams & Wilkins.