Epilepsy Dental Management Review J Contemp Dent Pract 2008

7/27/2019 Epilepsy Dental Management Review J Contemp Dent Pract 2008

1/14

The Journal of Contemporary Dental Practice, Volume 9, No. 1, January 1, 2008

Epilepsy and the Dental Managementof the Epileptic Patient

m: The aim o this article is to educate oral healthcare providers on the diagnosis and treatment o epilepsy

and seizure disorders. It also shows the impact of epilepsy on the oral cavity and provides suggestions on the

dental management of epileptic patients.

Review: Epilepsy and seizure disorders affect 1.5 million Americans. The disease is caused by a number

f genetic, physiologic, and infectious disorders as well as trauma. Treatment is primarily pharmaceutical but

an also be surgical. The disease itsel and the pharmaceutical management o ten have an impact on the oral

avity. Primary management considerations are the provision of good periodontal care and the restoration of the

teeth with stable, strong restorations.

Conclusions: With proper understanding of patients with epilepsy and seizure disorders and their medical

treatment, the dental care team can safely and effectively render dental care that will benefit the patient and

minimize the risk of oral health problems in the future.

Keywords: Epilepsy, seizure, gingival hyperplasia, oral medicine, dilantin, treatment planning, medically

omplex patients, special needs patients, status epilepticus, antiepileptic drugs

Citation: Jacobsen PL, Eden O. Epilepsy and the Dental Management of the Epileptic Patient. J Contemp

Dent Pract 2008 January; (9)1:054-062.

Abstract


2/14


Introduction

The word epilepsy is derived from the Greek

word epilambanein meaning to take or to seize.Between 400 BC and 200 AD Hippocrates,

Aretaeus, Celsus, and Plinius all providedcareful descriptions of major and minor seizures.Hippocrates even recognized that seizures

originate in t e rain.1

Modern medicine defines epilepsy as ac ronic neurological isor er c aracterize

by frequently recurrent seizures. A seizure isa sign of a disease, which manifests as anepisodic disturbance of movement, feeling, or

consciousness cause y su en sync ronous,inappropriate, and excessive electrical discharges

that interfere with the normal functioning of therain.

2

More than 1.5 million Americans have active

ep epsy.3 n t a cases are most common nchildren with another peak occurring in elderlypatients. The increased incidence in the elderly

is associate wit rain relate trauma suc asstroke, brain tumors, and Alzheimers disease.

Etiology and Pathogenesis

In approximately 70% of all cases the specificcause of seizures cannot be determined.

4These

cases are classi ied as idiopathic or primaryepilepsy. When the cause of the seizure is

known, the terms used are either acquired or

secondary epilepsy. The reason for secondaryepilepsy can e meta olic, structural, anfunctional abnormalities including seizuressecondary to head trauma, especially if

consciousness was lost or more than 30 minutes.The most common cause of adult epilepsy is

cerebrovascular disease (stroke, brain attack)

ollowed by primary and metastatic brain tumors.

Systemic disorders that can cause epilepsyinclude infections, hypertension, and diabetes as

well as electrolyte im alances, e y ration, anlack of oxygen. High doses and withdrawal fromchronic use of drugs such as heroin, cocaine,

ar iturates, amp etamines, an alco ol canalso lea to seizures. T ere appears to e a

genetic predisposition to epilepsy associated withc romosome 12 anomalies. T ese anomalies

increase the risk of epilepsy in children ofepileptic women.

5-6

Epilepsy pat ogenesis, at t e cellular level,relates to systems that maintain the balance

between excitation and inhibition of brainelectrical activity. There is a loss o inhibitory

activity or an overproduction of excitatory activity.The imbalance appears to occur in abnormal

cells or in ured cells, which become the oci o theseizure. Those cells create a burst of abnormalelectrical signals that spread to adjacent cells

creating a storm o electrical activity. As thestorm progresses, the seizure becomes apparent.

Classification of SeizuresAn epileptic seizure classification has been

developed by the Task Force on Classificationand Terminology of the International League

against Epilepsy (ILAE). The initial classificationwas created in 1970, then revised in 1981.

8The

classification of seizures is based on clinicalhistory and mani estations as well as laboratory,neurophysiologic, and radiographic studies. The

currently used classification of seizures is inTa le 1.

In addition to classifying seizures, in 1989 the

ILAE also classi ied the di erent epilepsies listedin Table 2. Researchers and physicians usethe International Classification of Seizures and

Epilepsies to identi y seizure types and speci icepilepsies, make a iagnosis, an to eci e on

treatment.

Clinical Presentation of Different

Seizure TypesAll seizures can be broadly separated into two

categories: partial or generalize seizures.Partial seizures are further divided into simple

and complex. Simple partial seizures manifest


3/14


Table 1. International Classification of Epileptic Seizures.7


4/14


Motor seizures involve a c ange in muscle activity.

Most often, the body stiffens or the muscles begin

to jerk in one area of the body such as a finger orwrist. Some partial seizures cause weakness ofone or more body parts, including the respiratorytract and vocal apparatus, which affect the ability

to reat e an speak. Motor seizures may alsoinclude coordinated actions such as hand waving,

eyelid fluttering, eyes rolling up, foot stomping, orteet clenc ing/grin ing.

as auras or symptoms a pat ent exper ences at

the beginning of the seizure. Such symptoms

may be the only manifestation of the seizure or itmay progress. Simple means consciousness isnot impaired and partial means only part of thecortex is disrupted by the seizure.

There are several types of simple partial seizures:

motor seizures, sensory seizures, autonomicseizures, an psyc ic seizures.

Table 2. International Classification of the Epilepsies.9


5/14


lost. The seizures usually last from one to threeminutes. The phase ollowing the seizure is called

the postictal period in which the patient is tired andconfused for a few minutes and then falls asleep.

When tonic-clonic seizures last more than fiveminutes or recur in a series of three or more

seizures wit out return to consciousness etweenattacks, a serious neurological emergency calle

convulsive status epilepticus has developed. Thisrequires imme iate me ical attention.

Absence (petit mal) seizures are the mostcommon type of generalized seizures occurring

in children between our and 14 years o age.This type of seizure starts with no warning. They

typically last from ten to 25 seconds. Petit malseizures requently occur in clusters and may take

place up to hundreds of times a day.2

There are two types o absence seizures: typicaland atypical. Typical absence seizures areassociated with a variety of signs and symptoms

such as symmetric clonic movements (rapidblinking), postural changes (e.g., truncal arching

or head drop), automatisms signs (often facialmovements), and autonomic changes (e.g., pallor,pupil dilatation, flushing, piloerection, tachycardia,

or salivation). Typical petit mal seizures donthave a postictal period, and they are induced by

yperventilation.

Atypical petit mal seizures are also characterizedy motor signs an c anges in muscle tone. T ey

may be followed by postictal confusion. They

often occur on awakening or during episodeso drowsiness, but they are not provoked by

hyperventilation. Typical absence seizuresare characteristic of idiopathic generalized

epilepsies an atypical a sence seizures occur insymptomatic generalized epilepsies.

Other subtypes of generalized seizures aremyoclonic, atonic, clonic, an tonic seizures.

Myoclonic seizures are shock-like musclecontractions that usually involved both sides of thebody at the same time. Myoclonic seizures canoccur in some healthy people as they fall asleep

at nig t. T is is calle enign nocturnal myoclonusor sleep jerks. This form of a seizure is considered

a nonepileptic type of seizure in spite of the fact

Sensory seizures cause changes in sensation.T ese sensory allucinations or illusions can

involve all types of sensations such as thefollowing:

Touch (e.g., tingling feeling or electric shockfeeling)

mell (often an unpleasant odor Taste (tasting things that are not present in

the mouth) Vision (e.g., a spot of light or blurring

Hearing (e.g., a click, ringing, or a personsvoice)

Orientation in space (e.g., spacing out or

spinning feeling)

Autonomic seizures cause changes in theautonomic nervous system. This may mani est

as a change in the heart and breathing rates,cause sweating, or an unpleasant sensation in the

a omen, c est, or ea .

Psychic seizures manifest as sudden emotions

such as ear, anxiety, depression, or happiness.This type of seizure can also make patients feel

as if they have lived through this moment before(deja-vu), familiar things seem foreign to them(jamais vu), or the world is not real.

During complex partial seizures, consciousness

is impaire to some egree. T ere is no memoryof what happened during such seizures. Lethargy

and confusion often occur after the seizure. Partialseizures usually last rom 30 seconds to twominutes. In 30% of patients with partial seizures,

the partial seizure evolves into a secondarygeneralize seizure. In suc cases t e excessive

electrical activity that starts in a limited areaspreads to involve both sides of the brain.

Generalized seizures such as tonic-clonic (grandmal) originate in all regions of the cortex. They

begin with an abrupt loss o consciousness,often in association with a cry. It is not a cry from

pain but rather from air being forced through

the contracting vocal cords. All arm, leg, chestan ack muscles ecome rigi . T e person willfall and their back may arch, then their musclesbegin to jerk and twitch. During this clonic phase

the tongue or cheek can be bitten, and rothyand bloody saliva may be expectorated from the

mouth. Bowel and bladder control may also be


6/14


person has no memory of the event, therefore,eyewitness observation is very help ul. Family

history, social history, and past medical historyare also important in making a correct diagnosis.

A neurological examination will be done to identifyareas of abnormal brain electrical activity, as

well as assess t e patients motor an sensoryskills, the functioning cranial nerves, hearing and

speech, vision, coordination and balance, mentalstatus, an c anges in moo or e avior.

Depending on the heath history and examinationfindings, laboratory work may be ordered. This

mig t inclu e loo stu ies an special testingsuch as EEG, CT, MRI, PET, neurosonography,

and lumbar puncture (Table 3). Because theEEG procedure is usually performed between

seizures, a person with epilepsy may have anormal reading. To increase the chances of

finding an abnormality on the EEG the clinicianmay manipulate patient-related variables suchas medication reduction, sleep deprivation,

yperventilation, exercise, or alco ol intake.

Other Medical Conditions Resembling

EpilepsySeveral disorders can often be mistaken for an

epileptic seizure: hyperventilation, hypoglycemia,migraine, transient ischemic attacks, syncope,

pseu oseizure, transient glo al amnesia, ansleep disorders. Of these, the most common

conditions confused with epilepsy are syncope,pseu oseizure, an panic attacks.

Table 4 differentiates pseudoseizure, panic attack,and syncope rom a true epileptic seizure.

Management

PharmacotherapyAbout 80% of patients with epilepsy are

controlle wit me ication. Antiepileptic rugs(AEDs) are used to treat or prevent seizures.

Prior to 1993, the choice of AEDs was limited

to traditional drugs, such as phenobarbital,primi one, p enytoin, car amazepine, anvalproate. Over the past eight years, several newmedications have been approved by the United

States Food and Drug Administration (FDA).Antiepileptic drugs are selected based on the

type of seizure, age of the patient, side effects,cost o the medication, and adherence to the

similar movements occur in myoclonic seizures.Epileptic myoclonic seizures ave a s ort

duration and typically have no postictal phase.They can occur in both primary and secondary

generalize epilepsies.

Atonic seizures or drop attacks manifest as a

sudden loss o muscle strength. As a result, theperson collapses to the ground. Such seizures

are associated with an increased risk of heador jaw injury. Generally these seizures begin

in childhood and typically last less than fiveseconds. They are associated with change ofconsciousness. Usually there are no postictal

symptoms. Atonic seizures are a de ining eatureof symptomatic generalized epilepsies.

Clonic seizures usually begin before three years

of age. They are characterized by rhythmic jerkingmovements of the extremities as a result of quick

repeat ng, non-comp ete musc e contract on,and relaxation. Generalized clonic seizures areessentially tonic-clonic seizures without the tonic

component. During clonic seizures consciousnessmay be impaired and postictal confusion occurs.

enerally tonic seizures, like clonic seizures, alsobegin in the first few years of life. During tonic

seizures truncal and facial muscles suddenlybecome stiff. The person will fall if the seizure

occurs w ile t ey are stan ing. T ese seizureshave the highest risk of traumatic injury to the

head, oral, and dental structures, secondary toalling and orced contraction o the jaw muscles.

Tonic seizures usually last five to 20 seconds,

and they are followed by postictal confusion.

Many people have more than one type of seizure.The features of each type of seizure may change

rom seizure to seizure or over time.

Diagnosing Epilepsy

The need or a diagnosis o epilepsy is usuallyprecipitated by a first seizure. The physician must

decide whether a seizure is in fact a real seizure

or another condition such as fainting.

There are three primary steps in the diagnosisof epilepsy: health history taking, neurological

examination, an la oratory testing.

A health history will include information about thefacts surrounding the seizure. Sometimes the


7/14


Nonpharmacological Therapies

Vagus Nerve Stimulation (VNS)Some people whose

seizures are unmanageablewith AEDs may bene it rom

vagus nerve stimulationwith a Neurocybernetic

Prosthesis (NCP). TheFDA approved the use ofVNS in 1997. It is approved

as an adjunct therapy orrefractory partial seizures in adults and

adolescents who are over 12 years old.12

The NCP is a small pacemaker-like electricpulse generating evice surgically placesubcutaneously over the left chest wall orunder the left pectoralis muscle. Small wires

place un er t e skin attac t e eviceto the left vagus nerve. The left nerve

is always used because the right one ismore likely to cause car iac complications.

use of the AED. If the seizure is not controlled

with one medication, an alternate drug is tried.I monotherapy is unsuccess ul, a second drugcan be added for polytherapy. Monotherapy

is preferable, since polytherapy increases theincidence o adverse e ects.

The most common adverse effects of therapy

wit AEDs are rowsiness, izziness, ataxia,and gastrointestinal upset. Anticonvulsants canalso cause pathological changes in the mouth.

The patient may have the ollowing signs andsymptoms: dry mouth; irritation or soreness of

tongue and mouth; red, irritated, or bleeding

gums; and swelling of the face, lips, or tongue.Other possible side effects of medication mayinclude bone loss, which can lead to osteoporosisover the long-term of use.

2Some AEDs cause

enlargement o the gums as a result o gingivalhyperplasia.

10Common drugs used to treat

epilepsy and their intraoral side effects are listedin Ta le 5.

Table 3. Laboratory tests for diagnosing epilepsy.


8/14


ocument t e longer t e patient as

epilepsy prior to surgery the greater therelapse risk and they are more likely to

ave postsurgical auras.16

There are fourwidely accepted surgical procedures:

focal resection, corpus collosotomy,emisp erectomy, an t e multiple su pial

transaction.13

Ketogenic Diet (KD)

After the mid-1990sthe ketogenic diet

was evelope as aneffective treatment forepilepsy. A recent study

s ows t e ketogeniciet may ecrease

seizure frequency up to

50%.17

The study also shows the ketogenicdiet to be most effective in children youngerthen ten years of age who do not respondto or cannot tolerate the side effects of

EDs. This high- at and low-carbohydratediet changes the bodys metabolism

from using glucose as a primary energysource to using ketones. But a p ysician

n electrical generator is programme to

send energy impulses to the brain. Whenthe person feels a seizure is starting, she/

e activates t e evice using a smallmagnet. The device sends electric impulses

through the vagus nerve to the brain toelp interupt t e seizure. During stimulation

the patient may experience the following

side effects: coughing, hoarseness, throatpain, numbness o the throat or chin, and,

in some cases, increased salivation anddysphagia.

SurgerySurgery is another

treatment option orpatients w o are

refractory to AEDs or

have seizures or sideeffects that significantlyimpair their quality oflife. They must also be

etween 12 an 50 years ol .13

Previousstudies have shown 75% of patients

become seizure free within the firstpostoperat ve year.

14,15Several studies

Table 4. Differences between true epileptic seizure, pseudoseizure, panic attack, and syncope (fainting).


9/14


Table 5. Side effects of anti-epileptic drugs (AED) on oral/dental structures.


10/14

10The Journal of Contemporary Dental Practice, Volume 9, No. 1, January 1, 2008

properly educated and instructed in oral hygieneand provided an understanding o how their oral

health impacts their general health.

T e two primary pro lems compromising t eability to maintain good oral health for patientswith epilepsy are the financial resources to afford

goo ealt care an , in some patients, mentalor physical handicaps which prevent them from

being properly managed or to cooperate in ageneral ental setting.

Based on the above considerations, it is apparentthe dental practitioner may need to appropriately

modi y the management and treatment planningbecause of an epileptic patients unique

circumstances (Table 6).

Dental Management

A thorough acquaintance with the patients health

history is the main prerequisite or success ultreatment and can prevent many complications.

Most patients wit epilepsy know t ey ave t edisease and are either on medication or know

they are vulnerable to seizures. This informations oul e elicite uring t eir initial visitwhen the health history is taken. If the patient

acknowledges they have epilepsy, then thequestions listed in Table 7 are appropriate. Some

epileptic patients may conceal their disorder for

has to take into consideration this typeo therapy has limited use because it

has various complications includingdehydration, gastrointestinal disturbances,

ypertriglyceri emia, yperc olesterolemia,hypoproteinemia, infectious diseases,hepatitis, acute pancreatitis, persistent

meta olic aci osis, osteopenia, renalstones, poor growt , an weig t loss.

18

Therefore, this diet should be followed onlyun er me ical supervision.

In addition, yoga, acupuncture, aromatherapy,and behavior psychotherapy improve the quality

o li e and help to reduce seizure activity or somepatients.

Considerations for the Dental Management ofthe Epileptic Patient

Epilepsy occurs in people who have a wide

range o socio-economic, educational,environmental, and other factors impacting theirhealthcare. Unlike non-epileptic patients, specific

considerations or epileptic patients include thetreatment of oral soft tissue side effects of their

medication and correcting damage to their teetht at as occurre secon ary to seizure trauma.

ental treatment planning must consi er t e

fabrication of a dental prosthesis designed tominimize risk of future damage or displacement

of teeth. The epileptic patient should also be

Table 6. The dental management of the Epileptic patient.


11/14


uring a ental visit it is important to explainto the patient and parents (if applicable) the

importance of good oral hygiene and adequatenutrition on their gingival health and general

ealt . It is also a goo time to explain w y it isimportant to use toothpaste and any supplemental

fluoride preparations for the prevention of dentaldecay, especially in those patients su ering romxerostomia.

T e clinician s oul keep in min stress is

one of the factors that can trigger a seizure.Appointments should be scheduled during a time

o day when seizures are less likely to occur, ipredictable, and to minimize stress and anxietyduring the appointment. Techniques such as

explaining t e ental proce ures to t e patientbefore starting and offering assurance and

support during the procedure are always useful.

This interaction allows the clinician to assess thestatus of the patient during the procedure and canreduce the patients worry and tension.

ig t can e a trigger in in ucing an epilepticseizure. Therefore, dark or colored glasses can

be used as eye protection and the operating light

ear o being re used dental treatment or theyconsi er epilepsy as an em arrassing isease. In

this case the information requested on the healthhistory regarding medications the patient takes

s oul alert t e entist to a possi le seizuredisorder.

The intention o such questions is to derive acomplete picture of the patients health. This

includes evaluating the impact of epilepsy intheir lives, identi ying any oral problems, and

minimizing the risk of their having an epilepticseizure during a dental visit. The information also

assists in managing and treatment planning orthe patient to minimize any oral or health risks inthe future.

As with all patients, the frequency of dental

check-ups and prophylaxis appointments should

be based on the patients needs. The goal is toecrease an prevent ental an perio ontal

disease and diseases of the oral mucosa. Therecall and hygiene interval may be more frequent

or epileptic patients due to increased risk orgingival hyperplasia secondary to use of an AED

such as phenytoin (Dilantin).

Table 7. Questions to be asked of dental patients with epilepsy.


12/14


to go through their seizure while minimizing anyunintentional injury during the event (Table 8).

Most seizures do not constitute an emergency.

But i the seizure has any o the characteristicsof those listed in Table 9, then it does constitutean emergency and medical help needs to be

ren ere an /or summone .

Treatment Planning Considerations

I the patient with epilepsy is in need o prosthetic

treatment, t e entist s oul consi er t efabrication of prosthetic restorations resistantto damage or displacement during an epileptic

attack. Displacement o a prosthesis riskspossible aspiration of the prosthesis into the

upper respiratory tract. Cast gold fixed bridges orimplant restorations are ideal. They o er the least

chance of displacement or fracture.

ll porcelain/ceramic restorations present ahigh risk of fracture, and removal prosthesesrun a greater risk of displacement. Hence,

t ey woul not e t e i eal c oice. T e patientshould be informed of their restorative options

and the benefits and risks of each. In mostcases personal inances usually dominate anytreatment decision, and their choice of restoration

must be controlled so it is directed only into themouth and not lashed into the patients eyes.

Most patients with epilepsy or a seizure disorder

can eit er e a equately controlle or knowwhether they are likely to have a seizure duringtheir time in the dental office. If patients are

a equately controlle wit t eir me ication,routine ental t erapy is relatively simple an

straightforward. Elaborate precautions by theealt care provi er w ic require extra time

or altering the office schedule provide littleadditional benefit.

Patients w ose seizure activity oes notrespond to anticonvulsants may have to have

a consultation with a neurologist prior to adental appointment. Such patients may require

additional anticonvulsant or sedative medication.

The use o conscious sedation and generalanesthesia is not contraindicated in patientswith epilepsy. In some situations nitrous oxide or

intravenous sedation may be necessary to sa elyand effectively provide dental care.

12

I a patient has a seizure during a dentalappointment, t e only t ing to o is to allow t em

Table 9. Characteristics of a seizure episode which require medical attention.

Table 8. Steps to minimize risk of injury during an epileptic seizure.


13/14

1The Journal of Contemporary Dental Practice, Volume 9, No. 1, January 1, 2008

years. Still, these patients have a variety of uniqueme ical an ental nee s. Patients wit epilepsy

can be safely managed in a general dental officeby an informed practitioner. A good health history

to ully understand the patients disease andthe medications they are taking is essential. Aproper oral exam to uncover any dental problems

and possible oral e ects o anti-epileptic drugsis necessary. Some simple and straightforward

treatment planning considerations will insure thepatients oral ealt is properly maintaine .

is commonly rendered based on financialrestr ct ons.

Conclusion

Epilepsy a ects one out o 200 Americans.The impact is even larger when the impact onthe families of epileptic patients is taken into

consi eration.

The management of epilepsy and the medicationsavaila le as improve vastly over t e last ten

References

1. Weaver DF. Epilepsy and Seizures: everything you need to know. New York: Firefly Books Inc,2001. p.1-4.

2. Turner MD, Glickman RS. Epilepsy in the oral and maxillofacial patient: current therapy. J OralMaxillofac Surg 2005; 63:996-1005.

3. Devinsky O. Epilpsy patient and family guide, 2nd ed. Philadelphia: Davis Company, 2002. p. 26-49.4. Annegers JF. The epidemiology of epilepsy. The treatment of epilepsy: Principles and Practice, 2nd

e . Baltimore: Williams & Wilkins, 1996. p. 165-172.5. Elia M, Guerrini R, Musumeci A, Bonanni P, Gambardella A, Aguglia U. Myoclonic absence-like

seizures and chromosome abnormality syndromes. Epilepsia 1998; 39(6):660-663.

. Elia M, Musumeci A, Ferri R, ammarata M. Trisomy 12p and epilepsy with myoclonic absences.rain & Development 1998; 20:127-130.

7. Sirven JI. Classifying seizures and epilepsy: a synopsis. Seminars in Neurology 2002;22 3 :237-246.

8. Proposal for revised clinical and electroencephalographic classification of epileptic seizures.

Commission on Classification and Terminology of the International League Against Epilepsy.Epilepsia 1981; 22:489-501.

9. Proposal for revised classification of epilepsies and epileptic syndromes. Commission onClassification and Terminology of the International League Against Epilepsy. Epilepsia 1989;

0(4):389-399.10. Greenwood M, Meechan JG. General medicine and surgery for dental practitioners. Part 4:

Neurological disorders. Br Dent J. 2003; 195(1):19-25.

11. Karolyhazy K, Kovacs E, Kivovics P, Fejerdy P, Aranyi Z. Dental status and oral health of patientswith epilepsy: an epidemiologic study. Epilepsia 2003; 44(8):1103-1108.

12. Bryan RB, Sullivan SM. Management of Dental Patients with Seizure Disorders. Den Clin North Am,2006; 50(4):607-623.

3. Devinsky O, Pacia S. Epilepsy 1: Diagnosis and treatment. Epilepsy surgery. Neurol Clin 1993;1(4):951-971.

14. Yoon HH, Kwon HL, Mattson RH, Spencer DD, Spencer SS. Long-term seizure outcome in patients

initially seizure-free after resective epilepsy surgery. Neurology 2003; 61(4):445-450.15. Spencer SS, Berg AT, Vickrey BG, Sperling MR, Bazil CW, Shinnar S, Langfitt JT, Wlczak TS, Paca

SV, Ebrahimi N, Frobish D. Initial outcomes in the multicenter study of epilepsy surgery. Neurology

2003; 61(12):1680-1685.16. Kossoff EH, Vining E, Pillas DJ, Pyzik PL, Avellino AM, Carson BS, Freeman JM. Hemispherectomy

for intractable unihemispheric epilepsy. Etiology vs outcome. Neurology 2003; 61(7):887-890.17. Wheless JW. Nonpharmacologic treatment of the catastrophic epilepsies of childhood. Epilepsia

2004; 45(5):17-20.18. Kang HC, Chung DE, Kim DW, Kim HD. Early- and late-onset complications of the ketogenic diet for

intractable epilepsy. Epilepsia 2004; 45(9):1116-1123.


14/14


About the Authors

Epilepsy Dental Management Review J Contemp Dent Pract 2008

Documents

Transcript of Epilepsy Dental Management Review J Contemp Dent Pract 2008