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CDHO Advisory: Epilepsy and Seizures

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with epilepsy and seizures.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Epilepsy and Seizures, 2023-03-04

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Epilepsy and seizures

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have epilepsy and seizures, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with epilepsy and seizures.

MAJOR OUTCOMES CONSIDERED

For persons who have epilepsy and seizures: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted

Terminology varies from centre to centre. That used for this Advisory is as follows.

Epilepsy, seizure disorder 

  1. is a persistent brain disorder characterized by the tendency to generate epileptic seizures that are caused by episodes of abnormal electrical activity in the brain, and that
    1. recur
    2. are spontaneous
    3. have no immediate precipitating or provoking factor
    4. are chiefly of three overarching types
      1. generalized onset seizures, which 
        1. appear to start simultaneously in both cerebral hemispheres
        2. affect both sides of the body
        3. are associated with alteration or loss of consciousness
        4. and are further classified according to motor (tonic-clonic or other motor)/non-motor (absence)
      2. focal onset (i.e., partial) seizures, which 
        1. start in a particular region of the brain
        2. produce signs and symptoms reflective of the part of the brain affected
        3. may progress to generalized seizure
        4. and are further classified according to aware/impaired awareness; motor onset/non-motor onset; and focal to bilateral tonic-clonic
      3. unknown onset seizures, which
        1. are classified according to motor (tonic-clonic or other motor/non-motor) and unclassified.
  2. is diagnosed in about 3 percent of persons who have reached the age of 80.
  3. may  
    1. be caused by 
      1. various medical conditions 
      2. injury that affects the brain
    2. have no identifiable cause.
  4. manifests as signs and symptoms that variously include
    1. momentary disruption of the senses
    2. short periods of unconsciousness or staring spells
    3. convulsions.

Other terminology used in this Advisory is as follows.

  1. Absence seizure (petit mal) seizure, a staring spell, that 
    1. usually lasts less than 15 seconds
    2. occurs most commonly under age 20 years, usually in the age range 6–12 years
    3. creates no apparent lasting effects except for erasure of any recollection of the seizure and the events that occurred during it
    4. may be accompanied by particular movements, such as eye-blinking.
  2. Apnea, a period of time during which breathing stops or is much reduced.
  3. Aura, sensation that a seizure is imminent, which 
    1. occurs more commonly with focal seizures, but, according to some authorities, may also occur with generalized tonic-clonic seizures, although the latter is more frequently associated with a prodrome
    2. occurs suddenly, may involves feelings of passivity or automatism, is of great intensity, and feels strange.
  4. Convulsion, alternative name for seizure.
  5. Clonic, description applied to spasms in which violent muscular contractions and relaxations take place in rapid succession; opposite of tonic.
  6. Dyspnea, shortness of breath, difficulty breathing.
  7. Eclampsia, seizures during pregnancy or the post-partum period that
    1. are not related to a preexisting brain condition
    2. present as new onset of generalized tonic clonic seizure and or of unexplained coma with signs or symptoms of preeclampsia.
  8. Epileptic seizure, so named to distinguish it from seizures associated with causes other than epilepsy.
  9. Febrile convulsions, seizures in a child triggered by a fever which occur 
    1. mostly between the age of 9 months and 5 years in 3–5 percent of otherwise healthy children
    2. without any brain or spinal cord infection
    3. without nervous system cause.
  10. Generalized tonic-clonic seizure, grand mal seizure, that
    1. involves the entire body
    2. comprises the phases
      1. tonic, which
        1. involves the rigid contracture of muscles, including respiratory muscles
        2. lasts for 10–20 seconds
        3. begins with flexion of the trunk and elevation and abduction of the elbows
        4. continues with 
          1. extension of the back and neck
          2. extension of arms and legs
        5. may be accompanied by apnea secondary to laryngeal spasm 
        6. presents signs such as
          1. increase in pulse rate and blood pressure
          2. profuse sweating
          3. tracheobronchial hypersecretion
      2. clonic, which
        1. follows the tonic stage with clonic convulsive movements, in which there is rhythmic shaking 
          1. that lasts longer than the tonic phase 
          2. during which may occur
            1. tongue-biting 
            2. voiding of urine and or feces
        2. together with the tonic phase lasts 1–2 minutes
      3. postictal
    3. occur at any age
    4. may occur as 
      1. a single episode
      2. part of a repeated, persistent condition that is diagnosed as epilepsy
    5. may be signalled by a prodrome
    6. is most often associated with the terms “seizure,” “convulsion,” or “epilepsy”.
  11. Focal (partial) seizure, which occurs
    1. when the abnormal brain electrical activity is confined to a limited area of the brain
    2. as one of two types
      1. simple, which affects neither memory nor awareness 
      2. complex, which affects 
        1. awareness or memory of events before, during, and immediately after the seizure
        2. behaviour
    3. may be signalled by an aura.
  12. Postictal state, the abnormal condition occurring between the end of an epileptic seizure and the return to the person’s normal condition that includes a variable period of unconsciousness
    1. during which the person becomes quiet and breathing resumes
    2. from which the person gradually awakens, variously 
      1. in a confused state
      2. displaying automatic behaviour
      3. with headache and muscular pain
      4. without recollection of the actual seizure. 
  13. Prodrome, a premonition which 
    1. differs from an aura
    2. presents hours or days before a seizure
    3. includes 
      1. anxiety
      2. difficulty concentrating
      3. ecstatic feeling, rare
      4. irritability
      5. lightheadedness
      6. mood changes
      7. sleep disturbances.
  14. Preeclampsia, hypertension and proteinuria with or without abnormal edema occurring after the 20th week of pregnancy or during the first 4–6 weeks post-partum.
  15. Seizure, secondary seizure, reactive seizure, refers to an episode of disturbed brain activity that causes changes in attention or behaviour, which
    1. also refers to the physical findings or changes in behaviour that occur after an episode of abnormal electrical activity in the brain
    2. will be experienced by some ten percent of people at some point in their lifetime
    3. includes the following types
      1. absence seizure
      2. epileptic seizure 
      3. febrile convulsions 
      4. generalized tonic clonic seizure 
      5. focal (partial) seizure
      6. eclampsia seizure during or after pregnancy.
  16. Convulsive status epilepticus, is variously defined, including the following: the active part of a tonic-clonic seizure lasts 5 minutes or longer; a person goes into a second convulsive seizure without recovering consciousness from the first one; or, a person has repeated convulsive seizures for 30 minutes or longer.2
  17. Tonic spasm, sudden, abnormal, involuntary muscular contraction that is continuing. 

Overview of epilepsy and seizures

Resources consulted

Epilepsy

  1. Occurrence, causes and risk factors
    1. in North America 
      1. is the third most common neurological disorder, after dementia (CDHO Advisory) and stroke (CDHO Advisory) 
      2. occurs as new diagnoses of epilepsy at the rate of 0.5–1 percent of the population per year, about 20,000 new diagnoses per year in Canada
      3. affects about 1 percent of the population, some 360,000 Canadians
      4. epileptic seizures are classified in 20–25 percent of instances as generalized 
      5. occurs at the highest rates in 
        1. children 
          1. below five years of age
          2. under the age of 15 of whom some 30 percent have epileptic seizures that cannot be adequately treated, and that increase the likelihood of 
            1. adaptive problems that prevent a normal life
            2. behavioural problems
            3. learning disabilities
            4. psychiatric disorders
        2. the elderly, in which occurrence is increasingly recognized, and which is associated with 
          1. increased risk of falls and injuries
          2. dementia (CDHO Advisory) or some of its features, such as memory loss 
      6. relative to the general population without epilepsy is associated with 
        1. increased death rate 
        2. reduced health-related quality of life 
        3. lower income and reduced employment prospects
        4. reduced school achievements
        5. increased stigmatization
        6. increased comorbidities, complications and associated conditions, in particular sleep problems, such as
          1. sleep disorders
          2. sleep deprivation 
          3. increased day-time sleepiness and seizures
    2. is associated with causes and risk factors that
      1. are poorly understood because in 50–60 percent of diagnoses no specific cause is found
      2. include 
        1. causes common to epilepsy and non-epileptic seizures
          1. brain tumour
          2. congenital brain defect
          3. congenital metabolic disorders, such as phenylketonuria
          4. dementia (CDHO Advisory)
          5. conditions that damage or destroy brain tissue
          6. infections3, including 
            1. brain abscess
            2. encephalitis
            3. HIV/AIDS (CDHO Advisory)
            4. meningitis
          7. stroke or transient ischemic attack (CDHO Advisory)
          8. traumatic brain injury
        2. causes more typically characteristic of non-epileptic seizures
          1. abnormal levels of sodium or glucose in the blood
          2. abuse of street drugs, such as cocaine and amphetamines (CDHO Advisory)
          3. alcohol-related withdrawal symptoms associated with heavy drinking (CDHO Advisory)
          4. high fever
          5. kidney failure (CDHO Advisory)
          6. liver failure (CDHO Advisory)
          7. withdrawal symptoms of medications, including 
            1. certain analgesics
            2. sleeping medications.
  2. Signs and symptoms
    1. vary among persons
    2. tend to be consistent in pattern for individuals from one recurrence to another
    3. may be heralded by an aura or a prodrome depending on the type of seizure
    4. vary according to types of seizure
      1. generalized tonic-clonic seizure
        1. usually involves
          1. muscle rigidity, followed by violent muscle contractions
          2. loss of consciousness
        2. may include
          1. apnea or dyspnea
          2. biting the cheek or tongue
          3. clenching of teeth or jaw
          4. cyanosis
          5. epileptic cry, caused by air forced through restricted glottis
          6. urinary and fecal incontinence 
        3. post-seizure may include 
          1. confusion
          2. drowsiness
          3. headache
          4. loss of memory for events surrounding the seizure 
          5. sleepiness that lasts for one hour or longer
          6. weakness of one side of the body for a few minutes to a few hours following the seizure 
      2. eclampsia seizure, which exhibits the clinical picture of generalized tonic-clonic seizure during or after pregnancy
      3. focal (partial) seizure, which 
        1. does not usually cause 
          1. loss of consciousness
          2. total loss of recollection of the seizure and concurrent events  
        2. may present any of the following 
          1. muscle-related effects, including
            1. abnormal head movements
            2. abnormal muscle contraction
            3. clonic activity
            4. forced turning of the head
            5. unilateral effects variously on
              1. arms
              2. legs
              3. part of the face
          2. vision-related and eye effects, such as 
            1. changes in vision
            2. dilated pupils
            3. forced turning of the eyes
            4. staring spells
          3. complex, repetitive movements, such as
            1. abnormal mouth movements
            2. behaviours that seem habitual
            3. chewing or swallowing without oral content
            4. lip smacking
            5. picking at clothing
          4. abnormal sensations that 
            1. are unilateral 
            2. spread
            3. may occur with or without motor symptoms
            4. include
              1. abdominal pain or discomfort
              2. nausea
              3. numbness, tingling and skin-crawling 
          5. psychosomatic effects, including
            1. alteration in mood or emotion
            2. hallucinations
            3. sensations of deja vu
            4. temporary mental blackouts, periods of time lost from memory
          6. changes in certain vital signs, including
            1. flushed face
            2. rapid heart rate
            3. sweating
      4. absence seizure
        1. lasts only a few seconds
        2. may
          1. occur often in a day
          2. have been occurring for weeks or months prior to recognition
          3. interfere with learning and school 
          4. be misunderstood as
            1. willful inattention
            2. misbehaviour
        3. commonly involves 
          1. loss of awareness of surroundings
          2. staring episodes, also called absence or absence spells
          3. sudden but temporary cessation of movement, talking, and other obvious activities
        4. may include changes in muscle activity, such as 
          1. chewing
          2. fluttering eyelids
          3. fumbling hands
          4. smacking of lips 
        5. may be triggered variously by 
          1. excessively heavy breathing
          2. flashing lights
        6. leaves no apparent after effects following the seizure, so that the young adult or child is
          1. fully awake
          2. thinking clearly
          3. unaware of the seizure.
  3. Medical investigation
    1. for new or severe seizures seen in a hospital emergency room, aims to
      1. identify seizures
        1. with a trigger, such as drug overdose
        2. without an obvious trigger
        3. occurring in a person known to have epilepsy which may be due to insufficient or inappropriate medication 
      2. diagnose the type of seizure
      3. exclude medical conditions that 
        1. cause seizures
        2. require treatment
    2. for differential diagnosis, which covers a broad range of conditions, involves
      1. tests for infectious diseases
      2. electroencephalography to study brain activity
      3. CT or MRI scan to determine the cause and location of the problem in the brain 
      4. planning treatment.
  4. Treatment may involve
    1. surgery if seizures are associated with
      1. abnormal blood vessels in the brain
      2. bleeding in the brain
      3. brain tumour
    2. medication which, if unsuccessful, leads to the diagnosis of medically refractory epilepsy
    3. vagus nerve stimulation (VNS), a form of neuromodulation, for medically refractory epilepsy
    4. deep brain stimulation (DBS), a form of neuromodulation, for medically refractory epilepsy
    5. medical alert wristbands or other jewelry to indicate the need for prompt emergency medical treatment in the event of a seizure.
  5. Prevention
    1. of a specific nature is lacking for most seizures
    2. includes use of helmets to prevent brain injuries that cause epilepsy
    3. generally involves encouragement 
      1. for persons to 
        1. diligently follow their medications regimens
        2. seek quality sleep
        3. reduce stress
        4. exercise
        5. maintain a healthy diet
        6. avoid substances of abuse and alcohol
      2. for family caregivers to
        1. observe and record any seizure information 
        2. help to ensure the person gets and complies with proper treatment.
  6. Prognosis is governed by epilepsy’s key but variable factors, including 
    1. its nature as a lifelong condition for many persons, who need to continue indefinitely their anti-seizure medications 
    2. its risk of sudden death which, though low, is nevertheless higher than in the non-epileptic population
    3. the risk of serious injury resulting from a seizure during driving or operating equipment
    4. the possibility that some persons with epilepsy may be able to reduce or even stop their anti-seizure medication in the absence of seizures for several years 
    5. the optimistic pattern of certain types of childhood epilepsy which cease or improve with age, usually in the late teens or 20s.
  7. Social considerations
    1. support groups
      1. In Canada, include
      2. In the USA, include
    2. greater likelihood of reduced health-related quality of life resulting from
      1. reduced income
      2. less likely to have full-time employment
      3. persistent stigmatization.

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with epilepsy and seizures but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Comorbid conditions, complications and associated conditions of epilepsy and seizures include the following.

  1. Developmental disorders including
    1. autism (CDHO Advisory)
    2. cerebral palsy (CDHO Advisory)
    3. dementia (CDHO Advisory)
    4. Down syndrome (CDHO Advisory)
    5. intellectual disability.
  2. Difficulty learning.
  3. Side effects of medications, which include
    1. gingival hyperplasia associated with
      1. carbamazepine
      2. phenytoin
      3. valproic acid
    2. adverse interactions between valproic acid and aspirin and nonsteroidal anti-inflammatory medications
    3. bleeding disorder (CDHO Advisory)
    4. xerostomia (CDHO Advisory).
  4. With tonic-clonic seizure, increase in various risks because 
    1. aura is usually absent so the seizure strikes with little or no immediate warning
    2. associated injuries are frequent, such as trauma 
      1. to the head 
      2. to the tongue, lips, and cheeks
      3. arising from minor accidents such as falls 
      4. arising from major accidents caused during a seizure while
        1. driving
        2. operating machinery 
      5. resulting from self-inflicted bites  
      6. resulting in vertebral compression fractures, well-known complications of seizures
    3. of risks of complications, such as
      1. aspiration pneumonia caused by inhalation of food or saliva during a seizure
      2. neurogenic pulmonary edema, a relatively rare form of pulmonary edema, which 
        1. is caused by an increase in pulmonary fluid
        2. develops a few hours after a seizure because, it is believed, of increased intracranial pressure which affects brain pathways that influence pulmonary function
      3. cardiac arrhythmias, which in epilepsy
        1. may reflect brain malfunction
        2. may be associated with the risk of sudden death of which the risk 
          1. is somewhat raised relative to the general population
          2. includes children and young persons with epilepsy.
  5. With epilepsy and seizures generally
    1. seizure occurring as
      1. a complication of stroke, are likely to be associated with permanent brain damage
      2. eclampsia, are a complication of pregnancy 
    2. inadequate healthcare related to lack of public and healthcare knowledge of modern approaches to epilepsy care 
    3. high prevalence of chronic comorbid conditions, including
      1. Alzheimer’s disease 
      2. bowel disorders 
      3. migraine
      4. stomach or other intestinal ulcers
      5. stroke
      6. urinary incontinence 
    4. proneness of persons with epilepsy to
      1. sleep instability 
      2. sleep deprivation which, with other unrecognized or untreated sleep disorders, increase the likelihood of daytime sleepiness and therefore of daytime seizures.

Oral health considerations

Resources consulted

  1. Dangers associated with epileptic and other seizures, which include
    1. 911 emergencies, such as
      1. status epilepticus 
      2. eclamptic seizure, which is life-threatening to the mother and the unborn child
      3. generalized tonic-clonic seizure, which may have serious consequences for the patient/client as a result of uncontrolled movements
      4. focal (partial) seizure, which may create risk of physical injury from uncontrolled movements
      5. any seizure that lasts longer than five minutes
    2. absence seizure, which may pass unnoticed yet may nevertheless cause distress to the patient/client who loses contact with his or her surroundings in the oral healthcare setting 
    3. increases in the likelihood of seizure because of 
      1. the Procedures 
      2. interactions among medications and oral healthcare procedures, including
        1. pro-convulsant effects of local anesthetics
        2. anticonvulsant effects of local anesthetics
      3. seizure-precipitating factors prior to the Procedures, such as 
        1. sleep deprivation
        2. alcohol intake 
    4. inadequacies in the provision or performance of routine precautions required to 
      1. reduce the likelihood of seizures, including 
        1. avoiding bright light in the patient/client’s eyes
        2. recognizing auras
      2. respond to seizures of any type occurring during or shortly after the Procedures
    5. failure to recognize or react appropriately to eclampsia
    6. failure to obtain medical advice relative to 
      1. need for 
        1. adjustments to existing medications 
        2. additional medication to reduce risk during the Procedures
      2. a history of recent onset of seizures
      3. a history of  
        1. comorbid conditions, complications and associated conditions
        2. prior problems during oral healthcare or minor surgical procedures.
  2. Appropriate, sensitive and informative communications with children, adults and family caregivers relative to the Procedures intended for a patient/client subject to epileptic or other seizures.
  3. Benefits of oral healthcare to persons subject to seizures with epilepsy and other conditions associated with seizures, who may need particular attention to oral health.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

Treatment

  1. Antiepileptic drugs (AEDs) and related medications, which are prescribed after a diagnosis has been established, are used to reduce future seizures; these include
  2. Other medications which may be prescribed for persons who experience seizures include
  3. Dietary supplements, include

Side effects of medications

See the links above to the specific medications.

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical and medications history-taking should 

  1. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  2. explore the need for advice from the primary or specialized care provider(s)
  3. inquire about
    1. pointers in the history of significance to epilepsy and seizures
    2. symptoms indicative of inadequate control of epilepsy and seizures, such as a history of recent onset or increasing frequency of seizures 
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. medications considerations, including over-the-counter medications, herbals and supplements
    5. presence of implanted neuromodulation devices, including vagus nerve stimulation and deep brain stimulation systems
    6. problems with previous dental/dental hygiene care
    7. problems with infections generally and specifically associated with dental/dental hygiene care
    8. the patient/client’s current state of health
    9. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

Because epileptic seizures and seizures from other causes may constitute an unstable medical condition that may affect the appropriateness or safety of scaling and root planing, including curetting surrounding tissue, the dental hygienist should be guided by the patient/client’s medical history.

  1. As appropriate, the dental hygienist should consult with the primary care physician to obtain advice about implementing or clearance for implementing the Procedures. 
  2. Medical clearance should be sought if the patient/client has an implanted neuromodulation device, including vagus nerve stimulation and deep brain stimulation systems.
  3. But with an otherwise healthy patient/client whose seizure-related condition is under control4 and who is complying with his or her prescribed medication regimen and who does not have an implanted neuromodulation device, the dental hygienist should implement the Procedures, though these may be postponed pending medical advice, which may be required 
    1. if the patient/client
      1. has symptoms or signs suggestive of comorbidity, complication or associated condition
      2. not recently or ever sought and received such advice relative to oral healthcare procedures
      3. recently changed significant medications, under medical advice or otherwise
      4. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
      5. is deeply concerned about any aspect of his or her medical condition
    2. if the parent or family caregiver is concerned about any aspect of the person’s condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

Useful Resources

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of epilepsy and seizures, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test 
    1. that he or she has a history of epilepsy and seizures
    2. of the medication he or she is taking
  2. should discuss, as appropriate 
    1. the benefits of oral hygiene for persons subject to epilepsy and seizures
    2. the precautions that are required during the Procedures
    3. the importance of the patient/client’s
      1. self-checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    4. the need for regular oral health examinations and preventive oral healthcare 
    5. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth 
    6. the importance of an appropriate diet in the maintenance of oral health
    7. for persons at an advanced stage of a disease or debilitation
      1. regimens for oral hygiene as a component of supportive care
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
      3. scheduling and duration of appointments to minimize stress and fatigue 
    8. comfort level while reclining, and stress and anxiety related to the Procedures
    9. medication side effects such as dry mouth, enlargement of lips, and overgrowth of gingival tissues and recommend treatment
    10. mouth ulcers and other conditions of the mouth relating to epilepsy and seizures, comorbidities, complications or associated conditions, medications or diet
    11. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have epilepsy and seizures.
  2. Reducing adverse effects, such as physical injury, by
    1. ensuring that appropriate precautions are provided for and implemented
    2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    3. using appropriate techniques of communication
    4. providing advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet. 

POTENTIAL HARMS

  1. Causing or provoking a seizure during the Procedures or failing to follow appropriate procedures when one occurs in a patient/client.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the risk posed by the patient/client’s epilepsy or seizures has been insufficiently considered
    2. in the presence of complications for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with epilepsy and seizures.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2011-08-01

DATE OF LAST REVIEW

2011-08-01; 2020-01-02; 2023-03-04

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, MEd

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2011, 2020, 2023 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.
2 The duration of continuous seizure activity used to define status epilepticus has varied over time, with the recent trend being to shorter definitional time.  Practically, once seizures have continued for more than a few minutes, treatment should begin without additional delay.  As with convulsive status epilepticus, non-convulsive status epilepticus (NCSE) also requires emergency medical treatment in a hospital, particularly given that NCSE predisposes to convulsive status epilepticus. NCSE is a term used to describe long or repeated absence or focal impaired awareness (complex partial) seizures.
3 While nervous system infections are usually thought of as provoking seizures, they may elevate risk of future epilepsy (i.e., recurrent seizures).
4 Patient/client should be seizure-free for several months to be considered controlled.