EPILEPTIC PATIENTS

[drmithila]

On the grounds of literature and own clinical experience, pathological changes in epilepitic patients have been described. Dental management procedures in these patients have also been presented. The unquestionable importance of prophylaxis, which may markedly minimize the impact of epilepsy on the incidence of mouth diseases, has been emphasised. It has also been stated that epileptic patients should receive specialised and integrated dental treatment

Epilepsy, also known as seizure disorder, encompasses several different modes of presentation. Patients of all ages, from early childhood to the elderly, who present for dental care may be taking anticonvulsants or may have an unanticipated seizure in the dental office. Dentists should be familiar with the varied manifestations of seizures, the medications used in their treatment and management of a seizure in the dental office. It is estimated that 1% of the population of the United States are afflicted with epilepsy. There is indication that the elderly are becoming included in that number because of their affliction with cardiovascular disorders. The word “epilepsy” raises anxiety in many people because they fear that such an event is life threatening. However, the term epilepsy applies primarily to prolonged or repetitive seizures requiring intervention by trained individuals

        

[drmithila]

Remove any sharp or dangerous objects from the patient’s mouth immediately. Orthodontic wires and pins used in certain procedures may not be possible to remove in time, but try.

Tend to the patient’s airway. The most important thing is that the patient is able to breathe — so tilt the patient’s head if necessary to ensure he can breathe easily. If possible, have someone who just monitors the patient’s breathing.

Place the patient in the supine position if possible. A dental chair can be useful for doing this. If the seizure doesn’t occur in a dental chair, try to position the patient on his side. However, do not restrain the patient or move him in any way that might interfere with his overall safety.

Guard the patient at all times. Make sure he is safe. A seizure usually ends within a couple of minutes or less, and there’s nothing you can do but let it pass. The patient will likely be unharmed so long as you maintain his physical safety.

Time the seizure. Paramedics and doctors will need to know how long it lasts. If it goes on for more than five minutes, call 911.

Administer emergency medication if emergency medical services asks you to. Dentists usually have medications including diazepam and midazolam that can help in case of extreme seizure. However, a dentist should not decide to give medications without instructions from 911 or unless five minutes have passed and no help is accessible.

Stabilize the patient’s oral cavity as soon as the seizure ends. Close any open holes or cavities and remove any appliances you weren’t able to when the seizure began. You won’t be able to continue dental treatment and the patient may be going with paramedics to the hospital, so his mouth should not be exposed to infection.

Provide a detailed report of the occurrence to paramedics or physicians as needed. Dentists have medical education and can often provide very useful observations and insights when patients experience medical problems.

        

[drmithila]

DIAZEPAM-THE DRUG OF CHOICE
first marketed as Valium ( /ˈvæliəm/) by Hoffmann-La Roche is a benzodiazepine drug. Diazepam is also marketed in Australia as Antenex. It is commonly used for treating anxiety, insomnia, seizures including status epilepticus, muscle spasms (such as in cases of tetanus), restless legs syndrome, alcohol withdrawal, benzodiazepine withdrawal and Ménière’s disease. It may also be used before certain medical procedures (such as endoscopies) to reduce tension and anxiety, and in some surgical procedures to induce amnesia.[1][2] It possesses anxiolytic, anticonvulsant, hypnotic, sedative, skeletal muscle relaxant, and amnestic properties.[3] The pharmacological action of diazepam enhances the effect of the neurotransmitter GABA by binding to the benzodiazepine site on the GABAA receptor leading to central nervous system depression.[4]

Adverse effects of diazepam include anterograde amnesia (especially at higher doses) and sedation as well as paradoxical effects such as excitement, rage or worsening of seizures in epileptics. Benzodiazepines also can cause or worsen depression. Long-term effects of benzodiazepines such as diazepam include tolerance, benzodiazepine dependence as well as a benzodiazepine withdrawal syndrome upon dose reduction; additionally after cessation of benzodiazepines cognitive deficits may persist for at least 6 months and may not fully return to normal, however it was suggested that longer than 6 months may be needed for recovery from some deficits.[4] Diazepam also has abuse potential and can cause serious problems of addiction. Urgent action by National Governments to improve prescribing practices has been recommended.[5][6]

Advantages of diazepam are a rapid onset of action and high efficacy rates which is important for managing acute seizures; benzodiazepines also have a relatively low toxicity in overdose.[4] Diazepam is a core medicine in the World Health Organization’s “Essential Drugs List”, which is a list of minimum medical needs for a basic health care system.[7] Diazepam is used to treat a wide range of conditions and has been one of the most frequently prescribed medications in the world for the past forty years. It was first synthesized by Leo Sternbach.[8]
Diazepam is mainly used to treat anxiety, insomnia, and symptoms of acute alcohol withdrawal. It is also used as a premedication for inducing sedation, anxiolysis or amnesia before certain medical procedures (e.g., endoscopy).[9][10]

Intravenous diazepam or lorazepam are first line treatments for status epilepticus;[4][11] However, lorazepam has advantages over diazepam including a higher rate of terminating seizures and a more prolonged anticonvulsant effect.[12] Diazepam is rarely used for the long-term treatment of epilepsy because tolerance to the anticonvulsant effects of diazepam usually develops within 6 to 12 months of treatment, effectively rendering it useless for that purpose.[13][14] Diazepam is used for the emergency treatment of eclampsia, when IV magnesium sulfate and blood pressure control measures have failed.[15][16] Benzodiazepines do not have any pain relieving properties of themselves and are generally recommended to be avoided in individuals with pain.[17] However, benzodiazepines such as diazepam can be used for their muscle relaxant properties to alleviate pain which is caused by muscle spasms, caused by various dystonias, including blepharospasm[18][19] Tolerance often develops to the muscle relaxant effects of benzodiazepines such as diazepam.[20] Baclofen[21] or tizanidine is sometimes used as an alternative to diazepam. Tizanidine has been found to be equally effective as other antispasmodic drugs and have superior tolerability than baclofen and diazepam.[22]

The anticonvulsant effects of diazepam, can help in the treatment of seizures, due to a drug overdose or chemical toxicity as a result of exposure to sarin, VX, soman (or other organophosphate poisons; See #CANA), lindane, chloroquine, physostigmine, or pyrethroids[13][23] Diazepam is sometimes used intermittently for the prophylaxis of febrile seizures which occur as a result of a high fever in children and neonates under 5 years of age.[4][24] Long-term use of diazepam for the management of epilepsy is not recommended; however, a subgroup individuals with treatment resistant epilepsy benefit from long-term benzodiazepines and for such individuals clorazepate has been recommended due to its slower onset of tolerance to the anticonvulsant effects.[4]

Diazepam has a broad spectrum of indications (most of which are off-label), including:
Treatment of anxiety, panic attacks, and states of agitation[9]
Treatment of neurovegetative symptoms associated with vertigo[25]
Treatment of the symptoms of alcohol, opiate and benzodiazepine withdrawal[9][26]
Short-term treatment of insomnia[9]
Treatment of tetanus, together with other measures of intensive-treatment[27]
Adjunctive treatment of spastic muscular paresis (para-/tetraplegia) caused by cerebral or spinal cord conditions such as stroke, multiple sclerosis, spinal cord injury (long-term treatment is coupled with other rehabilitative measures)[28]
Palliative treatment of stiff person syndrome[29]
Pre-/postoperative sedation, anxiolysis and/or amnesia (e.g., before endoscopic or surgical procedures)[28]
Treatment of complications with a hallucinogen crisis and stimulant overdoses and psychosis, such as LSD, cocaine, or methamphetamine.[13]
Prophylactic treatment of oxygen toxicity during hyperbaric oxygen therapy[30]

Dosages should be determined on an individual basis, depending upon the condition to be treated, the severity of symptoms, the body weight of the patient, and any comorbid conditions the patient may have.[13

        

[Drsumitra]

Contraindications

Use of diazepam should be avoided, when possible, in individuals with the following conditions:[35]
Ataxia.
Severe hypoventilation.
Acute narrow-angle glaucoma.
Severe hepatic deficiencies (hepatitis and liver cirrhosis decrease elimination by a factor of 2).
Severe renal deficiencies (for example, patients on dialysis).
Liver disorders.
Severe respiratory disorders.
Severe sleep apnea.
Severe depression, particularly when accompanied by suicidal tendencies.
Psychosis.
Pregnancy or breast feeding.
Caution required in elderly or debilitated patients.
Coma or shock.
Abrupt discontinuation of therapy.
Acute intoxication with alcohol, narcotics, or other psychoactive substances (with the exception of some hallucinogens, where it is occasionally used as a treatment for overdose).
History of alcohol or drug dependence.
Myasthenia gravis, or MG, an autoimmune disorder causing marked fatiguability.
Hypersensitivity or allergy to any drug in the benzodiazepine class

        

[Drsumitra]

Dependence

Improper or excessive use of Diazepam can lead to psychological dependence/drug addiction.[59] At a particularly high risk for diazepam misuse, abuse or psychological dependence are:
People with a history of alcohol or drug abuse or dependence[29][60] Diazepam increases craving for alcohol in problem alcohol consumers. Diazepam also increases the volume of alcohol consumed by problem drinkers.[61]
People with severe personality disorders, such as Borderline Personality Disorder[62]

Patients from the aforementioned groups should be monitored very closely during therapy for signs of abuse and development of dependence. Therapy should be discontinued if any of these signs are noted, although if physical dependence has developed therapy must still be discontinued gradually to avoid severe withdrawal symptoms. Long-term therapy in these people is not recommended.[29][60]

People suspected of being physiologically dependent on benzodiazepine drugs should be very gradually tapered off the drug. Although rare, withdrawals can be life-threatening particularly when excessive doses have been taken for extended periods of time. Equal prudence should be used whether dependence has occurred in therapeutic or recreational contexts.

Diazepam in and of itself is not a recreational drug, but may be used to either enhance or “come down” from the effects of other recreational drugs. For example, diazepam increases the euphoriant effects of heroin (and other recreational opiates), yet decreases the undesirable side-effects of cocaine and/or methamphetamine come-down.

[edit] Overdose

Main article: Benzodiazepine overdose

An individual that has consumed too much diazepam will typically display one or more of the following symptoms in a period of approximately four hours immediately following a suspected overdose:[29][63]
Drowsiness
Mental confusion
Hypotension
Impaired motor functions Impaired reflexes
Impaired coordination
Impaired balance
Dizziness

Coma

Although not usually fatal when taken alone, a diazepam overdose is considered a medical emergency and generally requires the immediate attention of medical personnel. The antidote for an overdose of diazepam (or any other benzodiazepine) is flumazenil (Anexate). This drug is only used in cases with severe respiratory depression or cardiovascular complications. Because flumazenil is a short-acting drug, and the effects of diazepam can last for days, several doses of flumazenil may be necessary. Artificial respiration and stabilization of cardiovascular functions may also be necessary. Although not routinely indicated, activated charcoal can be used for decontamination of the stomach following a diazepam overdose. Emesis is contraindicated. Dialysis is minimally effective. Hypotension may be treated with levarterenol or metaraminol.[13][29][63][64]

        

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