Health history taking z Memory of the event z Family history z Past medical history 2

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口腔病理科 On-Line KMU Student Bulletin

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原文題目(出處)： Epilepsy and the dental management of the epileptic patient (The Journal of Contemporary Dental Practice, Vol.9, No.1 , Jan 1 ,2008 )

原文作者姓名： Peter L. Jacobsen , Oleksandra Eden

通訊作者學校： University of the Pacific in San Francisco (Dr.Jacobsen);

San Francisco State University (Dr. Eden) 報告者姓名(組別)：陸穎恒王奕凱 (Intern A)

報告日期： 2008.02.12 內文：

Introduction Epilepsy:

z A chronic neurological disorder characterized by frequently recurrent seizures

z Seizures :

9 Sign of disease

9 Manifests as an episodic disturbance of movement, feeling, or consciousness caused by sudden synchrondrous, inappropriate, and excessive electrical discharges that interfere with the normal

functioning of the brain

z Most common in children and elderly patients

z Increased incidence in the elderly is associated with brain related trauma such as stroke, brain tumor, Alzheimer’s disease, etc.

Etiology:

z Primary epilepsy

9 Seizures with unknown cause 9 In approximately 70% of all cases z Secondary epilepsy

9 Causes can be metabolic ,structural and functional abnormalities 9 Most common cause is cerebrovascular disease, followed by primary

and metastatic brain tumors

9 Systemic disorders (infections , hypertension, DM, electrolyte imbalances, dehydration, lack of oxygen)

9 High dose and withdrawal from chronic use of drugs such as heroin, cocaine, barbiturates, amphetamines and alcohol.

9 Chromosome 12 anomalies

Pathogenesis:

Loss of inhibitory activity or overproduction of excitatory activity of brain electrical activity occurs in abnormal or injured cells

These cells create a storm of abnormal electrical signals, and as the storm progresses, the seizure becomes apparent.

Classification of Seizures:

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Classification of Epilepsies :

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Diagnosing Epilepsy 3 steps :

1. Health history taking z Memory of the event z Family history z Past medical history 2. Neurological examination 3. Laboratory testing

z EEG, CT, MRI, PET, neurosonography, lumbar puncture

Other Medical Conditions Resembling Epilepsy

Most common conditions confused with epilepsy are listed below:

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Management Pharmacotherapy :

z About 80% of patients are controlled with medication (antiepileptic drugs, AEDs)

z Choice of AEDs was limited (e.g. phenytoin, phenobarbital, primodone ,carbamazepine, valproate)

z AEDs are selected based on 9 Type of seizure

9 Age of the patient 9 Side effects

9 Cost of the medication 9 Adherence to the use of AED z Monotherapy followed by polytherapy z Side effects :

9 Drowsiness 9 Dizziness 9 Ataxia 9 GI upset 9 Dry mouth

9 Soreness of tongue and mouth 9 Gingival hyperplasia

9 Swelling of face ,lips or tongue 9 osteoporosis

Nonpharmacological Therapies:

Vagus nerve stimulation (VNS):

1. 主要針對某些無法利用AEDs來控制seizures的病人的另一種治療方式，利用 Neurocybernetic Prosthesis (NCP)的裝置來改善腦部不正常放電的情形。

2. 是一種小型類似pacemaker的electric pulse generating device，利用手術的方 式將之放置到左側胸壁或是左胸大肌(left pectoralis muscle)的皮下來治療。

Æ多數放置在左邊的原因是因為若放置在右邊容易產生心臟方面的併發症 3. 這個NCP利用設定好的程式去產生能量去刺激大腦，也就是當病人快要發生

seizure時會促使它進行放電的動作去改變本來要發作的大腦

4. 由於是刺激Vagus nerve的原理，因此本來迷走神經管理的行為就成了負作用

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，包括咳嗽，聲音嘶啞，喉嚨痛，喉嚨或是chin的的麻痺，甚至在某些情況 下造成吞嚥困難

Surgery:

1. 手術也是另一個非藥物治療的選擇之一，當seizure已經嚴重影響到病人的生 活且藥物無法控制時，就會考慮是否要以手術來治療。

2. 年紀多數適用在12~50歲之間的病患，研究指出約有75%的病患在術後第一 年完全沒有出現過seizure的症狀，Focal resection、Corpus collosotomy、

Hemispherectomy、Multiple subpial transaction是目前提出可接受的四種手 術方式。

Ketogenic Diet (KD):

1. 研究指出這種飲食改變方式可改善症狀到約50%以上，並且針對10歲以下無 法承受AEDs副作用的病患特別適合。

2. 這個高脂高碳水化合物的飲食方式主要是以改變身體的新陳代謝模式的原 理來治療seizure，從代謝葡萄糖改為代謝ketone類。

3. 副作用: Dehydration、Gastrointestinal disturbances、Hypertriglyceridemia

、hypercholesterolemia、Hypoproteinemia。

Dental Management of the Epileptic Patient:

1. 牙科治療必須要注意的地方:包括完整history taking、medication p’t taking

、定期回診檢查口腔、燈光勿照射到眼睛、牙齦腫大的處理等等。

2. 牙科治療上的處理原則基本上和一般沒有特別不同，但是當病人需要補綴物 的製作時，就必須要特別以Cast gold fixed或是Implant來做優先考量，因為 考量到發病的可能性以及日後拆除率的降低，上述兩種是較佳的選擇。

3. 再來是當一個seizure的病人來診時，要事先詢問的問題如下:一些病人最近的 身體狀況以及發病情形的頻繁度還有發病的因素都是要注意的重點。

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4. 當一個seizure患者在牙科門診中發病時，我們處理時的注意事項:

基本的處理原則為”讓這個發病自行停止”因為在發病中我們無法做任何治療的 動作，只能儘可能去減少任何會造成病患傷害的機會。

5. 最後是當患者出現以下狀況時，需要請求其他醫療上的支援:

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題號題目

1 下列哪種藥物會引起牙齦過度生長 (86國考)

(A) Phenytoin、cyclosporin、penicillin (B) Phenytoin、cyclosporin、nifedipine (C) Nifedipine、tetracycline、phenytoin (D) Tetracycline、penicillin、erythromycin

答案(C) 出處：Oral % Maxillofacial Pathology 2^nd edtition P146

Anticonvulsants (Phenytoin)、Calcium channel blockers (nifedipine)

、Cyclosporine、Erythromycine、Oral contraceptives

題號題目

2 Tegretol為治療顛癇的藥物有不少副作用，以下何者不是?

(A) 口乾

(B) 胃不適

(C) Glossitis

(D) 耳鳴

答案(D) 出處：