MANAGEMENT OF PATIENT WITH NEUROLOGIC DISORDERS

FAMOUS PEOPLE WITH EPILEPSY

SEIZURE DISORDERS

SEIZURE• A sudden excessive discharge of electrical

activity in the brain that usually causes a change in behavior.

• A symptom of an underlying disorder that affects the brain.

SEIZURE DISORDERS

• Common causes of acute, non-persistent seizures:– Metabolic abnormalities (hypoglycemia, alcohol

intoxication)– Drug-induced (lidocaine)– Febrile illness – Acute head trauma– Brain tumors– Brain abscess– Stroke– Meningitis, encephalitis– Illnesses such as eclampsia, hypertension, encephalopathy

EPILEPSY?

• A neurologic disorder characterized by transient, recurrent disturbance of brain function that may or may not be associated with impairment or loss of consciousness and abnormal movements or behavior.

EPILEPSY

• Most epileptic seizures occur randomly, however some occur with triggering events such as:– Missing a dose of antiepileptic medication– Flashing, flickering, or stroke lights– Certain times in the menstrual cycle– Stress– Loss of sleep– Excessive alcohol ingestion– Infection– Dehydration or starvation

DENTAL MANAGEMENTOF THE EPILEPTIC PATIENT

1. Identification of patient with seizure disorder.2. Establish the history of seizure disorder.

o Typeo When diagnosedo Severityo Frequencyo Degree of controlo Last seizureo Precipitating factors

3. List medications the patient is taking.

Adverse Drug Effects

• Sedation, dizziness, somnolence, nausea• Idiosyncratic (potentially serious and life-

threatening)– Rash, Stevens-Johnson syndrome, agranulocytosis,

thrombocytopenia, aplastic anemia, liver failure• 20% of patients taking Carbamazepine (Tegretol)

or Oxcarbazepine (Trileptal) experience a benign leukopenia with WBC counts less than 4000/ml, with transient decreases to less than 2500/ml.

Adverse Drug Effects

• Gingival hyperplasia – etiology unknown; found in about 50% of patient taking Phenytoin (Dilantin); usually evident within 2 to 18 months after starting treatment.

DENTAL MANAGEMENTOF THE EPILEPTIC PATIENT

3. Schedule proper frequency of oral hygiene and provide good oral hygiene instruction to ensure healthy periodontal tissue and teeth.

4. Insure proper dental lighting (no light directly in eyes).

5. Insure medications have been taken properly relative to dental appointments to minimize risk of seizure.

Management of Patient with a Seizure Disorder

1. Defer surgery until the seizures are well controlled.

2. Consider having serum levels of antiseizure medications measured if patient compliance is questionable.

3. Use an anxiety-reduction protocol.4. Take measures to avoid hypoglycemia and

fatigue in the patient.

Management of Patient with a Seizure Disorder

• If a patient has a seizure during a dental appointment, the only thing to do is to allow them to go through their seizure while during the event.

Steps to minimize risk of injury during an epileptic seizure

1. If it can be safely done, quickly remove all foreign material from the patient’s mouth.

2. The chair should be placedi n a supine position.3. If possible, turn the patient to their side in order to

minimize aspiration of foreign bodies orsecretions.4. Use passive restraint only to prevent injury that

may occur by the patient hitting nearby objects or to prevent them from falling out of the chair.

MANAGEMENT OF PATIENT WHO IS PREGNANT

MANAGEMENT OF PATIENT WHO IS PREGNANT

1. Defer elective surgery until after delivery, if possible.

2. Consult the patient’s obstetrician if surgery cannot be delayed.

3. Avoid dental radiographs unless information about tooth roots or bone is necessary for proper dental care. If radiographs must be taken, use proper lead shielding.

4. Avoid the use of drugs

MANAGEMENT OF PATIENT WHO IS PREGNANT

4. Avoid the use of drugs with teratogenic potential. Use local anesthetics when anesthesia is necessary.

5. Use at least 50% oxygen if nitrous oxide sedation is used.

6. Avoid keeping the patientin the supine position for long periods, to prevent vena caval compression.

7. Allow the patient to take trips to the rrestroom as often as needed.

Dental Medications to Avoid in Pregnant Patients

• Carbamazepine• Chloral hydrate• Chlordiazepoxide• Corticosteroids• Diazepam and other

benzodiazepines• Diphenhydramine

hydrochloride• Morphine

• Nitrous oxide (if exposure is <9 hours per week or oxygen conc. is less than 50%)

• Pentazocine hydrochloride

• Phenobarbital• Promethazine

hydrochloride• Tetracycline

Classification of Medications with Respect to Potential Fetal Risk

• Category A: Controlled studies in women have failed to demonstrate a risk to the fetus in the1st trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal harm remains remote. Example drugs or substances:– levothyroxine– folic acid– magnesium sulfate– liothyronine

Classification of Medications with Respect to Potential Fetal Risk

• Category B: Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in women or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the 1st trimester (and there is no evidence of a risk in later trimesters).Example drugs: – Metformin– Hydrochlorothiazide– Cyclobenzaprine– Amoxicillin– Pantoprazole

Classification of Medications with Respect to Potential Fetal Risk

• Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.Example drugs: – Tramadol– Gabapentin– Amlodipine– Trazodone– Prednisone

Classification of Medications with Respect to Potential Fetal Risk

• Category D: There is positive evidence of human fetal risk but the benefits from use in pregnant women may be acceptable despite the risk.Example drugs: – Lisinopril– Alprazolam– Losartan– Lonazepam– Lorazepam

Classification of Medications with Respect to Potential Fetal Risk

• Category X: Studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. – Atorvastatin– Simvastatin– Warfarin– Methotrexate– Finasteride