CASE REPORT

Oral Health Considerations and Dental Management for

Epileptic Children in Pediatric Dental Care
Mridula Goswami1, Smriti Johar2, Anusha Khokhar3

A b s t r ac t
Epilepsy is a chronic neurological disorder characterized by recurrent seizures. Epilepsy generally begins in childhood, potentially impeding
education, employment, social relationships, and the development of a sense of self-worth. The number of decayed and missing teeth, the
degree of abrasion, and periodontal indices are significantly worse in patients with epilepsy. Epileptic patients require special care during dental
treatment. A seizure episode in a dental clinic is a medical emergency, and it is imperative as an oral health care provider to have adequate
knowledge about this condition in order to render safer dental care to epileptic patients. There is a paucity of information in the medical literature
on the dental management of epileptic patients. The purpose of this case series is to elaborate on the oral health considerations in epileptic
patients and educate oral healthcare providers on the diagnosis, treatment, and emergency management of epilepsy, along with special dental
treatment needs in epileptic patients. The case series is a compilation of two cases of petit mal epilepsy and one case of generalized tonic-clonic
seizure with detailed descriptions of preventive seizure measures and dental management undertaken during the treatment of patients.
Keywords: Dental care, Epilepsy, Medical emergency, Seizure.
International Journal of Clinical Pediatric Dentistry (2023): 10.5005/jp-journals-10005-2516

Introduction 1–3
Department of Pediatric and Preventive Dentistry, Maulana Azad
According to World Health Organization (WHO), epilepsy is defined Institute of Dental Sciences (MAIDS), Delhi, India
as a chronic association of multiple etiologies which involves
Corresponding Author: Anusha Khokhar, Department of Pediatric
recurring episodes of paroxysmal brain dysfunction, which occur and Preventive Dentistry, Maulana Azad Institute of Dental
due to sudden disorder and excessive neuronal discharge.1 Epilepsy Sciences (MAIDS), Delhi, India, Phone: +91 7988874346, e-mail:
is characterized by seizures along with certain features such as [email protected]
altered perception, behavior, and mental activities, involuntary How to cite this article: Goswami M, Johar S, Khokhar A. Oral Health
muscle contractions, transient loss of consciousness, and chronic Considerations and Dental Management for Epileptic Children in
changes in neurological functions. Epileptic seizures are reversible Pediatric Dental Care. Int J Clin Pediatr Dent 2023;16(1):170–176.
and have a tendency to recur.2–4 Source of support: Nil
Seizures can be defined as the discontinuation of normal brain Conflict of interest: None
functions due to excessive or inadequate electrical discharges, which
Patient consent statement: The author(s) have obtained written
occur suddenly and result in episodic convulsions with certain other
informed consent froms the patient’s parents/legal guardians for
features, such as involuntary movements, altered consciousness, or publication of the case report details and related images.
disturbed perception.5,6 The occurrence of atleast two or more seizure
episodes is necessary for the diagnosis of epilepsy.7
A total of 50 million people worldwide are suffering from epilepsy
(WHO).1 The incidence of epilepsy in the pediatric population varies psychic seizures, and autonomic seizures. Complex partial seizures
from 41 to 187 cases/100,000 children. The prevalence of epilepsy are of two types—seizure with simple partial-onset, after which
in children ranges from 3.2 to 5.5/1,000 in developed countries awareness is impaired, and seizure in which awareness is impaired
and 3.6–44/1,000 in underdeveloped countries.8 at the onset of a seizure. In simple partial seizures, consciousness is
About 25% of cases of epilepsy occur due to brain damage not impaired, and only part of the cortex is disrupted by the seizure.
caused by infection, injury, cerebrovascular accident, or birth In complex partial seizures, the memory associated with partial
trauma. Idiopathic epilepsy involves the remaining 75% of cases seizures is lost, and the partial seizure develops into a secondary
for which there are no identifiable causes (Table 1).3 generalized seizure later on.
The etiology of epileptic seizures depends upon the individual Generalized seizures usually lead to loss of consciousness, and
seizure threshold, which is genetically determined and it interacts convulsions can or might not occur. Generalized seizures have the
with the precipitating factors or triggers (Table 2). following subtypes—absence, generalized myoclonic tonic-clonic,
Seizures are classified into three categories—focal (formerly and atonic. Absence seizures, also known as petit mal seizures, are
called partial), followed by lethargy and confusion. Aberrant characterized by staring without any reaction to an external verbal
neuronal activity is more widespread in generalized seizures. In 30% stimulus with the blinking of eyes or nodding of the head. Generalized
of patients with generalized and unclassified (Table 3). Focal/partial tonic-clonic seizures [formerly called grand mal (GTCS)] involve
seizures are further of two types—simple and complex. Simple bilateral symmetric convulsive movements in which muscles stiffen,
partial seizures are divided into motor seizures, sensory seizures, followed by jerking of all limbs along with impaired consciousness.

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 Oral Health Considerations and Dental Management

The duration of convulsions is usually 2–3 minutes and ends with and also frequently lead to tooth injuries or, in some cases, cause
a gurgling sound. After the seizure, the patient may experience maxillofacial trauma, especially in patients who suffer from poorly
convulsions or disorientation. Myoclonic seizures are associated controlled generalized tonic-clonic seizures. Hence, dentists need to
with sudden, brief lightning-fast movements without any obvious have adequate knowledge about epilepsy and its impact on the oral
disturbance of consciousness. In atonic seizures, the body tone is lost, and dental health of epileptic patients to manage such conditions.
which often results in a head drop or fall (Flowchart 1). An attack of epilepsy during dental treatment constitutes a
The probability of a seizure attack in the dental chair in epileptic medical emergency, and additional precautions must be taken to
patients necessitates the need for all dental professionals to be avoid such attacks in the dental chair. Epileptic patients require
well-trained in managing such emergencies. The management additional considerations for behavior guidance which include
strategy for the epileptic attack in a dental chair is mentioned in Table 4. cognitive and behavioral intervention in which an attempt is made
Epileptic patients have a significantly higher number of carious to establish a good relationship with the child using effective
and missing teeth as compared to the general population as epileptic communication. The dentist should know about the patient’s
people generally experience difficulty with motor skills, which includes education level, cognitive ability, cooperation in dental settings,
issues with fine motor skills, gross motor skills, and coordination factors that trigger uncooperative behavior, pacifying strategies,
which negatively influences the tooth brushing ability.9 Gingival details about routine or schedule, current therapies, and other
hyperplasia is seen in 50% of the patients taking the antiepileptic drug useful provisions, as these might have an impact on the dental care
Phenytoin within 12–24 months after the treatment starts. Epileptic to be delivered. Understanding these factors will help improve the
seizures usually lead to minor oral injuries, such as tongue biting, delivery of care and communication. To gain the child’s cooperation
in the provision of oral healthcare, the dentist needs to establish a
Table 1: Etiology of epilepsy based on age groups trusting relationship with the child patient, which depends on the
Etiology of epilepsy based on age groups establishment of effective communication. The dentist should be
Young infants loving, tender, and caring to the child.
• Metabolic disturbances
• Congenital brain malformations Table 3: Classification of seizures according to the ILAE
• Infection Focal/partial seizures
• Perinatal intracranial trauma Simple partial seizures (awareness not impaired)
• Hypoxia or birth asphyxia • With minor signs (focal motor, versive, phonatory)
Children and adolescents • With somatosensory or specialsensory symptoms
• Idiopathic • (somatosensory, visual, auditory, olfactory, gustatory)
• Infection • With autonomic symptoms
• Trauma • With psychic symptoms (déjà vu, illusions, hallucinations)
Adults Complex partial seizures
• Cerebrovascular disease • With a simple partial-onset followed by impairment of
• Alcohol abuse awareness
• Brain tumors • With impairment of awareness at the onset
• Idiopathic Partial seizures evolving to secondarily generalized seizures
• Head injury • Simple partial seizures evolve into generalized seizures
• Complex partial seizures evolve into generalized seizures
Table 2: Precipitating/triggering factors for seizure • Simple partial seizures evolve into complex partial and then
generalized seizures
Precipitating/triggering factors for seizure Generalized seizures
Hunger • Absence seizures
• Stress • Myoclonic seizures
• Fever • Clonic seizures
• Hormonal disturbance • Tonic seizures
• Photosensitivity • Tonic-clonic seizures
• Sleep deprivation Infection • Atonic seizures
• Metabolic disturbance Unclassified seizures

Flowchart 1: Classification of seizures

International Journal of Clinical Pediatric Dentistry, Volume 16 Issue 1 (January–February 2023) 171
 Oral Health Considerations and Dental Management

Table 4: Measures to minimize injury when a child patient has an attack patients. Each procedure was explained to the children slowly,
of epilepsy in the dental setup simply, and repetitively. Appropriate management strategies
• The attendant should stay calm and remain with the patient. were used to prevent seizure attacks in the dental chair and for
• The area around the patient should be cleared of anything hard emergency management of seizures.
or sharp to prevent injury.
• If the patient has any fluid or dental instrument/material in Case 1
their mouth, he should be rolled onto their side immediately. A 4.5-year-old child reported to the department with a complaint
This will help the patient breathe and prevent the aspiration of of pain on chewing in the upper back teeth region. There was no
foreign objects. history of spontaneous pain or nocturnal pain. During history
• The dentist should place the dental chair in a supported, supine
taking, the mother reported that the patient’s first seizure attack
position as near to the floor as possible.
was at 1 year of age. The patient stared in blankness during the
• If the patient is not on the chair, he/she should be eased onto
the floor, and their head should be protected by placing seizure episode and seemed lost, with persistent eye blinking
something soft and flat, like a foldable jacket, shirt, towel etc., for 8–10 seconds. Such episodes occurred 10–15 times a day. The
under the head. parents made attempts to arouse the child, but it was of no use.
• The patient should not be restrained during the convulsions as The parents consulted a neurologist, and hence the diagnosis
it might cause difficulty in breathing. of petit mal epilepsy was made. The patient was on the tablet
• Fingers should not be placed in his or her mouth because of the ethosuximide, and the last seizure had occurred 1.5 years back.
risk of being bitten. Before the examination, the patient was taken to a separate dental
• Eyeglasses must be removed operatory with no bright lights or loud noises.
• Anything around the neck, like a necktie, scarf etc., that may On oral examination, dental caries was recorded with respect
make it hard to breathe should be loosened. to deciduous right and left maxillary second molars (55, 65) and
• Time the seizure. Call the medical emergency team, or dial deciduous right and left mandibular second molars (75, 85). Overall,
101 (the medical emergency helpline number in India). Call
the patient had relatively average oral hygiene. The patient’s
the emergency team or dial 101 (medical emergency helpline
parents were informed about the diagnosis and explained the
number in India) if the seizure lasts longer than 5 minutes.
treatment plan.
The carious teeth were restored using glass ionomer cement
Table 4 measures to minimize injury when a child patient has (Fig. 1). The restorations were completed uneventfully. The parents
an attack of epilepsy in the dental setup. of the child were counseled and motivated about the need to
The aim of this case series is to discuss the oral health maintain good oral hygiene, reduce the sugary substrates from
considerations in epileptic children and describe the oral diet and keep regular follow-ups with the dentist every 6 months.
rehabilitation strategies for these patients using suitable behavior
management techniques. Case 2
A 5-year-old child was reported to the department with a complaint
of brownish discoloration on the upper right back region of the jaw
Case Description for 1 year. There was no history of pain or any discomfort during
The present case series is a compilation of three cases, two cases chewing. On history taking, it was found that the child suffered from
of absence seizure and one case of a generalized tonic-clonic periodic attacks of violent seizures since 3 years of age. The patient
seizure. The patients reported to the Department of Pedodontics would roll back his eyes, clench his teeth, and become stiff prior to
and Preventive Dentistry. A detailed case history, including falling onto the ground. The parents did not have knowledge about
demographic details and previous relevant medical and dental the disease prior to visiting the doctor, so they tried local means
history, followed by a thorough clinical examination, was performed like inhalation of burnt chili fumes, but it was of no use. There was
for each patient. The treating Neurologist’s consent was obtained, one episode of tongue biting during the seizure attack. He was
and the blood reports were screened to assess the overall health taken to a pediatrician and a neurologist, where he was identified
and identify conditions such as infections, iron deficiency anemia, as having a case of generalized right and left focal epileptic seizures
or diabetes that may trigger the seizures. The treatment was associated with language and learning difficulties. The last seizure
scheduled under the same antiepileptic drug regime as suggested had occurred 6 months ago. The frequency of seizures was almost
by the Neurologist. once every week. The patient was currently placed on tablet
carbamazepine and tablet risperidone.
General Preparations for the Cases On oral examination, dental caries was diagnosed with respect
The appointment was scheduled in the morning hours. At the to the maxillary right primary molar (54). The parents of the child
initial visit, the patients were quite concerned and anxious about were informed about the diagnosis and explained the treatment
the dental clinical environment. As stress is a crucial factor that plan. Since the last seizure had occurred 6 months ago, intravenous
provokes seizures, it was ensured that stress-causing factors midazolam (0.15 mg/kg) was kept ready in the emergency tray. In
were eliminated before the start of treatment. It was planned to addition to that, a plastic spatula wrapped in cotton was kept ready
keep the treatment session short, and sudden stimulants such to avoid accidental tongue biting in case of seizure.
as shimmering bright lights and extreme noise were removed The dental restorations were carried out using glass ionomer
from the environment. The patients were relaxed by the treating cement in the affected tooth (Fig. 2). These restorations prevented
dentist and taken to a separate operatory away from the general accidental fracture in case of a seizure due to clenching of teeth.
clinic. They were familiarized with the operatory and introduced The parents were counseled and motivated about the need to
to the dental equipment in a stepwise manner with tender love maintain oral hygiene and make regular follow-ups with the dentist
care (TLC). The tell-show-do approach was very helpful for these every 6 months.

172 International Journal of Clinical Pediatric Dentistry, Volume 16 Issue 1 (January–February 2023)
 Oral Health Considerations and Dental Management

Figs 1A to E: (A) Frontal view; (B and C) Maxillary occlusal and mandibular occlusal view depicting carious deciduous, maxillary second molars,
and deciduous mandibular second molar on right and left sides of the jaw. Postoperative pictures—(D and E) Maxillary occlusal and mandibular
occlusal view depicting Cermet restoration wrt to carious teeth

Figs 2A to D: (A) Frontal view; (B and C) Maxillary occlusal and mandibular occlusal view depicting carious maxillary deciduous first molar. Postoperative
view—(D) Maxillary occlusal view depicting glass ionomer restoration wrt to carious tooth

International Journal of Clinical Pediatric Dentistry, Volume 16 Issue 1 (January–February 2023) 173
 Oral Health Considerations and Dental Management

Case 3 Wang et al. state that carious and missing teeth and periodontal
A 7-year-old female reported to the department with a complaint indexes are significantly worse in patients with epilepsy.11 In a study
of pain in her lower right back teeth region for 1 month. The pain by Percival et al., it was found that epileptic children had more
was spontaneous and nocturnal. The patient had a medical history plaque on permanent teeth, increased gingivitis, and increased
of petit mal epilepsy since 2 years of age. During the seizure attack, anterior-tooth trauma, yet fewer dental caries compared to
she stared in blankness and did not blink her eyes for 15–20 seconds. controls.12 In an epidemiologic study, Karolyhazy et al.13 found that
Such episodes occurred 20–30 times a day. Her parents were from patients with epilepsy showed significantly worse oral hygiene
lower socioeconomic backgrounds, and she was taken to local status compared to healthy subjects. These authors state the higher
unqualified doctors for her condition, and she did not improve. index of dental disease–including caries, injury, and periodontal
Thereafter, she was taken to a government hospital where she was disease—is a consequence of the combined effect of neglected
diagnosed with petit mal epilepsy. She was placed on the tablet of oral hygiene, poor socioeconomic background, and injuries in
ethosuximide. The patient showed gradual improvement and was the oral cavity. Epileptic seizures lead to minor oral injuries, such
free of seizures for 1.5 years. as accidental tongue biting, but also frequently lead to tooth
On oral examination, the patient was diagnosed with carious injuries and, in some cases, maxillofacial trauma. Around 50% of
deciduous mandibular right and left second molar (75, 85) and patients taking the antiepileptic drug phenytoin develop gingival
maxillary deciduous first molar on the right side (54). The radiograph hyperplasia within 12–24 months of initiation of treatment.14
revealed irreversible pulpitis concerning the mandibular right In 1989, the International League Against Epilepsy (ILAE) divided
second molar (85). The parents were informed about the diagnosis epilepsy based on its etiology into idiopathic, cryptogenic, and
and explained the treatment plan. symptomatic groups, as described in Table 2. Idiopathic epilepsies
A pulpectomy followed by a crown placement was carried out were presumed genetic, cryptogenic epilepsies were likely to have
on the involved mandibular molar on the right side, and the other a cause, and symptomatic epilepsies had an identifiable cause
two teeth were restored with cermet cement (Fig. 3). The treatment (Table 5).
was completed uneventfully. The parents were counseled and The epileptic children are more anxious about dental care than
motivated regarding the need to maintain oral hygiene and commit their normal healthy counterparts, which may lead to decreased
to regular follow-ups with a dentist every 6 months. frequency of dental visits and, subsequently, poor oral health. The
most effective treatments for epilepsy-related behavioral issues
Discussion often involve a combination of medication and cognitive and
World Health Organization (WHO) data suggests that epilepsy is one behavioral intervention. Along with the child’s name, age, and chief
of the most significant contributors among neuronal and psychiatric complaint, the dentist should determine the presence and type of
diseases toward the global burden of human suffering.1 Epilepsy epilepsy and, when appropriate, the name(s) of the child’s medical
adversely affects the education and social skills in a child. Epilepsy care provider(s) and also ask the parent how long it has been since
elevates a child’s risk of developing mental health and behavioral the time of onset of last seizure and what are the trigger factors. This
problems by a factor of five, which include hyperactivity, anxiety, helps in predicting the chances of the occurrence of a seizure on the
depression, attention deficit, aggression, and an autism spectrum day of surgery. A dentist must obtain clearance from the treating
disorder.10 neurologist prior to treating an epileptic child. The child should be

Figs 3A to F: (A) Frontal view; (B and C) Maxillary occlusal and mandibular occlusal view depicting carious deciduous mandibular second molar on
both sides and maxillary deciduous first molar on the left side; (D) Postoperative frontal view; (E) Maxillary occlusal depicting Cermet restoration
with respect to maxillary left the first molar; (F) Mandibular occlusal view Cermet restoration with respect to the mandibular right first molar and
stainless steel crown with respect to mandibular left first molar

174 International Journal of Clinical Pediatric Dentistry, Volume 16 Issue 1 (January–February 2023)
 Oral Health Considerations and Dental Management

Table 5: ILAE,1989 Classification and etiology of epileptic seizure13 to the patient. Only one instruction should be given at one
Generalized epilepsies and syndromes time.15 However, an overdose of local anesthetic might lead to
generalized tonic-clonic convulsions. The patient must be rewarded
Idiopathic (with age-related onset listed in order of age)
after the completion of each procedure (positive reinforcement).
• Benign neonatal familial convulsions
• Benign neonatal convulsions After treatment has been completed, the patient should be escorted
• Benign myoclonic epilepsy in infancy by a parent/attendant out of the dental operatory. The lights should
• Childhood absence epilepsy (pyknolepsy) be dimmed until the patient walks out.
• Juvenile absence epilepsy General anesthesia should be avoided as far as possible during
• Juvenile myoclonic epilepsy (impulsive petit mal) the treatment of epileptic patients, and only local anesthesia
• Epilepsy with GTCS seizures on awakening should be administered since it does not interact with standard
• Other generalized idiopathic epilepsies not defined antiepileptic drugs.
aboveCryptogenic or symptomatic (in order of age) In the present case series, a strong emphasis was placed
West syndrome (infantile spasms, Blitz-Nick-Salaam Krjdmpfe) on taking the history of the disease in an appropriate manner.
Lennox-Gastaut syndrome Before the start of treatment, clearance was obtained from the
Epilepsy with myoclonic-astatic seizures treating neurologist. The appointments were scheduled in the
Epilepsy with myoclonic absences
early hours of the day, and it was ensured that the child had taken
Symptomatic
his/her morning dose of the antiepileptic medication he/she was
Nonspecific etiology
• Early myoclonic encephalopathy currently placed on. The seizure-provoking factors were kept
• Early infantile epileptic encephalopathy under control by appropriate precautionary measures, such as
• Other symptomatic generalized epilepsy suppression burst operating in a separate clinic that was free from loud noises
epilepsies not defined above and bright lights. An emergency tray containing all required
Specific syndromes drugs, including diazepam, midazolam, dobutamine, phenytoin,
• Epileptic seizures may complicate many disease states. Under disposable syringes, a sphygmomanometer, equipment for
this heading are included diseases in which seizures are a physical safety like a plastic spatula wrapped in gauze pieces,
presenting or predominant feature and a portable oxygen cylinder was kept ready all the times. The
Epilepsies and syndromes undetermined, whether focal or epileptic children were successfully managed with a TLC approach
generalized and by the use of appropriate behavior management techniques
With both generalized and focal seizures such as desensitization, tell-show-do, modeling, etc., with TLC,
• Neonatal seizures which eliminated the need for anesthesia.
• Severe myoclonic epilepsy in infancy
• Epilepsy with continuous spike-waves Conclusion
• Acquired epileptic aphasia (Landau-Kleffner) without To safely manage an epileptic child in a dental clinic, it is
unequivocal generalized or focal features. All cases with imperative that the dental practitioner should be aware of the
generalized tonic-clonic seizures in which clinical and unique medical and dental needs of such children, along with
electroencephalogram findings do not permit classification seizure prevention and management strategies. The child should
as clearly generalized or localization-related, such as in many be handled with love and care. It is best to manage the epileptic
cases of sleep GTCS, are considered not to have unequivocal child using behavior management strategies so that the need
generalized or focal features during slow wave sleepner-
for general anesthesia or conscious sedation is avoided. The
syndrome) defined above
treatment planning considerations to ensure the patient’s oral
Special syndromes health are simple and straightforward. Dental procedures have an
Situation-related seizures (Gelegenheitsan-Falle) inherent tendency to cause seizures, and as a result, dentists must
• Febrile convulsions possess adequate background knowledge about the patient’s
• Isolated seizures or isolated status epilepticus medical condition and appropriate management strategies,
• Seizures occur only when there is an acute metabolic or especially since epilepsy is the commonest medical emergency
toxic event due to factors such as alcohol, drugs, eclampsia,
in dental practice.
nonketotic hyperglycemia
Importance of the Case Series
well under cover of medicine and must take his/her morning dose This case series attempts to elaborate on the oral health
of medication prior to a dental operation. considerations in epileptic patients and educate oral healthcare
It is important to eliminate stress-causing factors before providers, including both general dentists and pediatric dentists, on
starting the treatment because stress might provoke seizures. the diagnosis, treatment, and emergency management of epilepsy,
The patient’s appointment must be placed in the morning hours along with special dental treatment needs in epileptic patients. The
of the day, the timing of treatment sessions must be limited, and treating dentist ascertained that the children were comfortable and
sudden stimulants such as extremely bright lights and too loud had a sense of security, for which the various behavior management
noises should be avoided. Understanding the patient’s sensitivities, approaches were utilized during the treatment, which established
aversions, cognitive level, and triggers to negative behavior will help a trusting relationship with the child as well as the parents. It also
improve the delivery of care and communication. describes the emergency management protocol for an epileptic
Effective communication is the key to establishing a good attack in the dental chair since it is a medical emergency. During the
relationship with the child, which includes being loving, tender, and treatment, it was ensured that the dental clinics were equipped with
caring. The dentist must listen to the patient actively, and dental the required emergency drugs and equipment in case an epileptic
procedures must be explained slowly, simply, and repetitively seizure occurred during the treatment.

International Journal of Clinical Pediatric Dentistry, Volume 16 Issue 1 (January–February 2023) 175
 Oral Health Considerations and Dental Management

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