Management of a high risk epileptic patient under conscious sedation: A multidisciplinary approach.

Epilepsy, characterized by the risk of recurrent seizures, is a chronic disease that afflicts about 5% of the world's population. The main dental problems associated with epileptic patients include gingival hyperplasia, minor oral injuries, tooth trauma, and prosthodontic problems, which require the dental treatment. Stress and fear are the most common triggering factors for the epilepsy in dental chair. Therefore, a more appropriate method of treating such epileptic patients may be warranted. Conscious sedation is a technique of providing good anesthesia and analgesia to patients, the main advantage of which is the patient's rapid return to presentation levels. Midazolam used as a sedative agent has anticonvulsant properties. This case report highlights a case requiring multiple dental procedures carried out in a high risk epileptic patient under conscious sedation.

INTRODUCTION

Epileptic seizures are the second most common medical emergency arising during dental procedures.[1] Epileptic patients commonly present with an array of conditions which includes drug-induced gingival hyperplasia, gingival bleeding, deep periodontal pockets, periodontal disease; and decayed teeth with poor oral hygiene, missing teeth, minor oral, and tooth injuries.[23]

Increased risks among patients with epilepsy have been documented for medical or dental procedures. The incidence of epilepsy during any dental procedure can be made practically nil by sedation dentistry. This case report describes the multiple dental treatment procedures done as a single stage in a poorly controlled epileptic patient under conscious sedation.

CASE REPORT

A 32-year-old male patient reported to our center with the complaint of swollen gums in lower anterior region. The clinical examination revealed gingival overgrowth on the labial aspect from distal of 33 extending to distal of 43 region with periodontal probing depth of around 6 mm, OPG revealed deep caries in 11 and 12 and root stumps in 18 [Figure 1]. His medical history revealed a history of epilepsy since 14 days of his birth with frequent epileptic episodes. His medications included Eptoin 100 mg, Sodium Valproate 500 mg, and Levetiracetam 500 mg, thrice daily. He was considered a high risk patient for any dental procedures under local anesthesia as he had poor control of the disease, in spite of taking the maximum recommended dosage of anticonvulsants. So, conscious sedation was considered a safe technique as it reduces the risk of stress-induced epilepsy.

Figure 1

Preoperative OPG

After obtaining the medical fitness and informed consent of the patient, the treatment plan included gingivectomy in relation to lower anteriors, crown lengthening in relation to 11 and 12, endodontic therapy in relation to 11 and 12, and extraction of 18 in single sitting under conscious sedation.

PROCEDURE

Conscious sedation

Patient was assessed under American Society of Anesthesiologists (ASA) physical status 2, for intravenous sedation (IV) with midazolam. Patient was kept nil per oral for 6 hours before procedure and premedicated with tablet PAN -D 40 mg (pantoprazole) and advised not to take any anticonvulsants on the day of the procedure because of the possibility of drug interaction. Using a 20 G cannulae right dorsal vein was cannulated. 5 mgs of midazolam was induced to achieve VERRILL sign. The patient was monitored throughout the procedure using pulse oximeter and noninvasive blood pressure monitor [Figure 2]. Hemodynamics was maintained throughout the surgery. Diclofenac sodium was also infused to prevent postoperative pain.

Figure 2

Preoperative view

Treatment

The depth of periodontal pocket was around 6 mm in lower anteriors. Based on the extension of gingival enlargement, gingivectomy was performed using No. 15 Bard-Parker blade by giving the external bevel incision at least 3 mm coronal to mucogingival junction after marking the pockets using Crane-Kaplan pocket marker. The excised marginal and interdental tissues were then removed using the curettes and interdental knife. Kirkland Knife was used to recontour the gingiva [Figure 3]. Periodontal dressing was placed. Histologic features of excised tissue confirmed the gingival overgrowth as drug-induced gingival enlargement.

Figure 3

Immediate postoperative view after gingivectomy of lower anteriors, endodontic therapy and crown lengthening in 11 and 12

Adequate plaque control was emphasized in this patient because the recurrence of drug-induced gingival enlargement in surgically treated cases is common.[4]

Inadequate clinical crown length for the retention of the crown was observed in relation to 11 and 12. Crown lengthening was done on the buccal and the palatal aspect with the electrosurgical scalpel [Figure 4] in such a way that biologic width was preserved.

Figure 4

Crown lengthening using electrocautery

Standard access preparation was done on the palatal aspect, incisal to the cingulum in 11 and 12. Working length was determined with the help of electronic apex locator and confirmed using a radiograph. Cleaning and shaping was done using a step back technique with ISO K files to a master apical file size 60 (ISO K-file). Obturation was done with gutta-percha by cold lateral compaction technique. All the treatment procedures were carried out in a single sitting [Figure 3].

Postspace preparation was done in 11 and 12 using gates glidden drills and paeso reamers, maintaining apical 5 mm of gutta-percha. A custom-made postcore was fabricated using nickel-chromium alloy [Figure 5], which was luted with Type I GIC. Metal ceramic crowns were fabricated and luted in 11 and 12 [Figures 6 and 7]. Patient was reviewed after 6 weeks [Figure 8] and 6 months [Figure 9]. The results were found to be satisfactory.

Figure 5

1-week postoperative view with postspace preparation in 11 and 12

Figure 6

2 weeks postoperative view after completion of all treatment

Figure 7

Postoperative radiograph

Figure 8

6 weeks postoperative view

Figure 9

6 months postoperative view

DISCUSSION

A total of 200,000 new cases of epilepsy are diagnosed each year. In developing countries, the rate has increased to 43/1000 people.[5] Prevalence is found to be more in males than females.[6]

Conscious sedation was suggested as the patient did not have control over the disease in spite of taking maximum dosage of anticonvulsant. The patient hailed from poor socioeconomic strata and was hesitant to come for multiple visits to get his dental treatment done. As IV sedation produces time compression effect, it was decided to do all the treatment procedures in one appointment as he wouldn’t be aware of any long appointment hour. IV sedation is chosen over inhalational sedation with nitrous oxide because IV midazolam as such is an anti-convulsant.

Stress is an important precipitating factor for epilepsy. As the patient is thoroughly distressed by the IV administration of midazolam, the possibility of stress-induced convulsion is zero. This prevents stress-induced increase in blood pressure, and the resultant exaggerated sedation gives the excellent control of blood pressure, the degree of bleeding during the procedure is considerably reduced.

Diazepam and midazolam each may have advantages for IV sedation. Midazolam is found to be effective for shorter dental procedures for rapid onset of action, predictable amnesic effects, and relatively faster recovery where diazepam required an average of 15 min longer to recover accuracy as measured by perceptual speed test.[7] IV midazolam is a safe and effective sedation method for use in children and adolescents with about 83% of patients scored “very good” and “excellent” overall behavior when assessed with ASA score[8] and IV midazolam showed more positive overall behavior when compared with oral midazolam and oral diazepam.[9] The use of midazolam showed 89% effective and safe when used for dental procedures in patients with neurological and behavioral disturbances.[10]

Hypoxia which is the important cause of precipitating the convulsion has to be avoided during the sedation. So, this patient's oxygen status was monitored continuously using pulse oximeter and supplement oxygen was kept as a standby, to be used in case of emergency.

As the patient was able to get all the dental procedures done in three visits instead of seven visits, he was highly satisfied with the treatment plan.

Assuming that this patient had undergone the procedure in a conventional manner (seven visits), patient would have been subjected to three courses of antibiotics and pain killers for each specialty work. In this case scenario, the patient needed only one course of antibiotic and pain killer.

CONCLUSION

The judicious use of conscious sedation in this case not only helped us to treat the patient in a much safer environment, but also had forementioned few advantages. This case report proves that a multidisciplinary approach in a poorly controlled epileptic patient can be safely and successfully carried out in a dental chair under conscious sedation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.