A Practical Approach to Special Care in Dentistry

In March 2017, the International League Against Epilepsy (ILAE), a group of the world's leading epilepsy professionals, introduced a new method to group seizures ( Table 1.2.3). The main changes are:‘Partial’ becomes ‘focal’‘Awareness’ is used as a classifier of focal seizuresThe terms dyscognitive, simple partial, complex partial, psychic and secondarily generalized are eliminatedNew focal seizure types include automatisms, behaviour arrest, hyperkinetic, autonomic, cognitive and emotionalAtonic, clonic, epileptic spasms, myoclonic and tonic seizures can be of either focal or generalised onsetFocal to bilateral tonic–clonic seizure replaces secondarily generalised seizure Table 1.2.3 New classification of epilepsy.Source: Adapted from Scheffer, I.E., Berkovic, S., Capovilla, G. et al. (2017). ILAE classification of the epilepsies: Position paper of the ILAE Commission for Classification and Terminology. Epilepsia 58: 512–21.Type of seizureType of epilepsy (EEG activity)AetiologyFocalGeneralisedUnknownFocalGeneralisedGeneralised and focalStructuralGeneticInfectiousMetabolicImmuneUnknownNew generalised seizure types are absence with eyelid myoclonia, myoclonic absence, myoclonic–atonic, myoclonic–tonic–clonicSeizures of unknown onset may have features that can still be classified

In view of this, seizures are divided into 3 main groups depending on:Site of onset in the brain: focal/generalised/unknownLevel of awareness: aware/impairedPresence of other symptoms: motor/non‐motor

This is summarised in Table 1.2.4

The diagnosis is established mainly based on clinical findings and electroencephalograms (EEGs) ( Figure 1.2.6) Table 1.2.4 Clinical presentation of seizures.Source: Adapted from Scheffer, I.E., Berkovic, S., Capovilla, G. et al. (2017). ILAE classification of the epilepsies: Position paper of the ILAE Commission for Classification and Terminology. Epilepsia 58: 512–521.Type of seizureCharacteristicsSigns/symptomsFocal onset (may affect one lobe or a large part of one hemisphere)Focal aware or focal impaired awarenessMotor onset or non‐motor onsetCan be followed by a bilateral tonic–clonic seizureMotor symptomsAutomatisms (lip‐smacking, chewing movements, running, cycling, kicking, repeatedly picking up objects or pulling at clothes)Loud cry or screamTwitching, jerking or stiffening movements of a body partSudden loss of muscle tone or limbs suddenly becoming stiffNon‐motor symptomsChanges in sensation, emotions, experiencesFeeling of déjà vu (feeling like you have been here before)Unusual smell or tasteSudden intense feeling of fear or joyNumbness or tinglingVisual disturbances (coloured/flashing lights or hallucinations)Generalised onsetMotor (tonic–clonic/other) or non‐motor (absence)Tonic–clonicTypically last 1–3 minAt the start of the seizure:The person becomes unconsciousBody goes stiff and they may fallMay cry outMay bite their tongue or cheekDuring the seizure:Jerk and shake as their muscles relax and tighten rhythmicallyBreathing might be affected and become difficult or sound noisySkin may change colour and become very pale or bluishIncontinence may occurAfter the seizure:Often feel tired, confused, have a headache or want to sleepAbsenceMore common in childrenCan be frequentLast a few secondsTypical absences: ‘daydreaming’, blank, unresponsive, may be missedAtypical: start and end more slowly, can last longer, may also include reduced muscle toneUnknown onsetMotor (tonic/clonic/epileptic spasms) or non‐motorVariable symptoms as described aboveUnclassifiedDue to inadequate information/inability to place in the above categories Figure 1.2.6 Electroencephalogram (EEG) showing epileptiform activity.

High‐resolution structural images (high‐field magnetic resonance) and functional radionuclide imaging (positron emission tomography/single‐photon emission computed tomography) can be useful ( Figure 1.2.7)

Genetic testing has gained importance in diagnosing some forms of epilepsy

Drug treatment with glutamate inhibitors (e.g. carbamazepine, lamotrigine, phenytoin and topiramate)

Gamma‐aminobutyric acid enhancers (e.g. barbiturates, benzodiazepines, gabapentin, primidone, tiagabine, valproate and vigabatrin) Figure 1.2.7 Magnetic resonance imaging (MRI) can identify structural changes in the brain that may cause seizures.

Surgery for drug‐resistant focal epilepsy (resection or disconnection of a circumscribed cerebral area, or vagal nerve stimulation)

The prognosis is determined by the underlying disease, the extent of the brain damage and the severity and frequency of the seizures

The estimated mortality of status epilepticus (generalised tonic–clonic seizures that last more than 5 minutes) is approximately 20%

The risk of premature death in people with epilepsy is up to 3 times higher than for the general population

Approximately 80% of people with epilepsy live in low‐ and middle‐income countries

Unfortunately, 75% of people with epilepsy living in low‐income countries do not receive the treatment they need

In many parts of the world, people with epilepsy and their families suffer from stigma and discrimination

The religious beliefs prevalent in some countries have resulted in a portion of the population still believing that epilepsy is caused by supernatural possession, resorting to religious healing for its treatment

In Africa, Asia and Latin America, alternative therapies such as medicinal herbs are often used to treat epilepsy (e.g. rhizomes of Acorus calamus and leaves from the Bacopa monnieri plant), most of which have not been pharmacologically evaluated

The socio‐economic and cultural environment significantly affects accessibility to drug treatment, which can jeopardise access for 75–90% of individuals with potentially treatable epilepsy in low‐income countries

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6 Robbins, M.R. (2009). Dental management of special needs patients who have epilepsy. Dent. Clin. North Am. 53: 295–309.

7 Schöpper, M., Ludolph, A.C., and Fauser, S. (2016). Dental care in patients with epilepsy: a survey of 82 patients and their attending dentists and neurologists in southern Germany. Int. Dent. J. 66: 366–374.

8 Thijs, R.D., Surges, R., O'Brien, T.J., and Sander, J.W. (2019). Epilepsy in adults. Lancet 393: 689–701.

A 15‐year‐old patient is referred by the Ear, Nose and Throat (ENT) specialist for an orthodontic assessment. There is concern that the patient's palatal morphology may be responsible for his chronic nasal respiratory distress ( Figure 1.3.1).

Child of a primiparous mother who had Steinert myotonic myopathy (also known as myotonic dystrophy type 1)