Seizures and Epilepsy in the Dental Practice
Seizures and Epilepsy in the Dental Practice
Recognition, Emergency Management and Midazolam
By Garry Perkins, former Paramedic and Founder of Sussex First Aid Courses Ltd
A seizure occurring in the dental chair can be an extremely challenging medical emergency for the whole dental team.
Having spent more than 35 years working in emergency care as a paramedic, as well as many years teaching annual medical-emergency CPD to dental teams, I believe seizure management is an area where preparation, good history-taking and calm teamwork can make an enormous difference.
For a patient with established epilepsy, a seizure may be something they and their family have managed many times before.
For the dental team, however, it may be the first seizure they have ever witnessed.
The priorities are therefore straightforward:
Protect the patient. Time the seizure. Maintain the airway. Know when to call 999. Follow the patient's emergency plan.
Not every seizure looks the same
When we say the word seizure, many people immediately imagine a tonic-clonic seizure involving loss of consciousness, stiffening and rhythmic jerking movements.
However, seizures can present in many different ways.
A patient may:
Suddenly stop responding
Stare blankly
Make repetitive movements
Become confused
Experience unusual sensations
Develop muscle jerking
Lose muscle tone
Become unconscious and experience a tonic-clonic seizure
This makes a good medical history particularly important.
Medical history may be your best friend
Before starting dental treatment, ask patients with known epilepsy about their condition rather than simply recording the word “epilepsy” on their medical history.
Useful questions include:
What type of seizures do you normally experience?
When was your last seizure?
How long do they normally last?
Is there anything that commonly triggers them?
Do you have a warning or aura?
What does your normal recovery look like?
Do you have an individual emergency care plan?
Are you prescribed emergency rescue medication?
Have you brought that medication with you today?
This information can be extremely valuable if the patient subsequently becomes unwell.
A patient who has an established epilepsy emergency plan should be encouraged to share it with the dental practice where appropriate.
Consider possible triggers
Patients may identify individual triggers for their seizures.
These may include factors such as:
Stress or anxiety
Missed medication
Lack of sleep
Illness
Alcohol
Changes in medication
Flashing lights in the relatively small number of people who have photosensitive epilepsy
Dental anxiety and the stress associated with treatment are therefore worth considering during treatment planning.
It may sometimes be appropriate to discuss appointment timing, anxiety management or other adjustments with the patient in advance.
If a tonic-clonic seizure occurs
The first priority is to stop dental treatment immediately.
Remove instruments and equipment from the patient's mouth if this can be done safely.
Do not attempt to continue treatment.
Call other members of the dental team for assistance and start timing the seizure.
Protect the patient from injury
Make the immediate area as safe as possible.
Dental chairs can generally be positioned to help protect and support the patient, but the exact response will depend on the circumstances.
Protect the patient's head where possible.
Remove nearby equipment that could cause injury.
Do not restrain the patient
One of the most important first-aid principles is:
Do not hold the patient down.
Do not attempt to stop their arms or legs moving.
Guide and protect rather than restrain.
Never put anything in their mouth
This myth still persists.
Never put an object, instrument or your fingers between the patient's teeth.
A person cannot swallow their tongue.
Trying to force something into their mouth risks causing injury to the patient and potentially to the member of staff trying to help.
Time the seizure
Accurate timing is extremely important.
Do not guess afterwards.
As soon as seizure activity is recognised, check the time or start a timer.
Record:
When the seizure began
When active convulsive movements stopped
When the patient began to respond
When they returned towards their normal baseline
This information may be extremely useful to the ambulance service and subsequent medical team.
Why five minutes matters
Most tonic-clonic seizures stop spontaneously within a relatively short period.
However, a convulsive seizure continuing for 5 minutes or more should be treated as convulsive status epilepticus.
This requires urgent emergency management.
Do not wait 20 or 30 minutes before deciding that the patient needs help.
Five minutes is an important emergency threshold.
If the patient's individual emergency management plan specifies earlier intervention, follow that plan.
When should the dental team call 999?
Call 999 if:
A convulsive seizure reaches 5 minutes
The seizure lasts significantly longer than is normal for that patient
Another seizure begins without adequate recovery
It is believed to be the patient's first seizure
The patient has sustained a significant injury
Breathing does not return to normal
Consciousness does not recover as expected
The patient's presentation differs significantly from their normal seizure pattern
You are concerned about the patient's condition for any other reason
Tell the ambulance service that the patient is experiencing, or has experienced, a prolonged seizure or suspected status epilepticus where appropriate.
Use an ABCDE approach
Once it is safe to do so, assess the patient systematically.
A – Airway
Ensure the airway is open.
After the active convulsive phase has stopped, reposition the patient as required to help maintain the airway.
Suction may be appropriate where necessary and where staff are trained and equipped to use it.
B – Breathing
Assess:
Respiratory rate
Breathing effort
Chest movement
Skin colour
Oxygen saturation where available
Provide oxygen in accordance with current dental emergency guidance and the patient's clinical condition.
C – Circulation
Assess:
Pulse
Blood pressure where appropriate
Skin colour
Perfusion
D – Disability
Assess level of consciousness.
Check blood glucose where appropriate, particularly where hypoglycaemia could be contributing to the presentation.
E – Exposure
Look for:
Injury
Bleeding
Evidence of a fall or head injury
Medical-alert information
The patient's emergency care plan
Emergency medication carried by the patient
Oxygen in the dental setting
Current dental emergency guidance includes high-concentration oxygen as part of the management of a prolonged convulsive seizure where appropriate.
The practice should maintain sufficient emergency oxygen and ensure staff are trained and competent in using the equipment.
Do not wait until an emergency occurs to discover that nobody knows how to assemble the oxygen equipment.
Emergency equipment needs to be:
Available.
Accessible.
Checked.
Familiar to the team.
Buccal midazolam and prolonged seizures
Some patients with epilepsy will have prescribed emergency medication for prolonged seizures.
One medicine commonly used in the UK is buccal or oromucosal midazolam.
NICE recommends a benzodiazepine such as buccal midazolam as an emergency first-line option for convulsive status epilepticus in the community when appropriate.
For dental teams there are two situations that must be clearly distinguished:
The patient's own prescribed medication
A patient may arrive with their own prescribed emergency midazolam and an individual emergency management plan.
Where this occurs, the dental team should know in advance:
Where the medication is kept
Who is trained and authorised to administer it
What the patient's emergency plan requires
When 999 should be called
What monitoring is required afterwards
Follow the patient's current prescription and emergency plan.
Practice-stock midazolam
Midazolam held as practice emergency stock is subject to medicines and controlled-drug governance.
Midazolam is a Schedule 3 controlled drug.
Practices stocking it should therefore have appropriate procedures covering responsibility, storage, access, checking, use, documentation and disposal in accordance with current legislation and professional guidance.
The exact preparation and dose used must be checked against the current BNF/BNFC and applicable dental medicines guidance.
Why I would not rely on memory for drug doses
During training, I often discuss the effect that stress has on otherwise experienced clinicians.
Human factors matter.
When someone is convulsing in your dental surgery, it is not the ideal moment to rely entirely on somebody remembering a drug dose from a CPD session twelve months earlier.
Have current emergency drug information readily available.
Use the patient's individual treatment plan where applicable.
Check the medicine.
Check the prescribed dose.
Check the preparation.
Check the expiry date.
Use clear closed-loop communication between team members.
And when in doubt:
Call 999 and ask for clinical support.
What happens after the seizure?
Once the active seizure has stopped, many patients enter a post-ictal recovery period.
The patient may be:
Very tired
Confused
Disorientated
Headachy
Emotional
Unable to remember what happened
Temporarily weak
Slow to respond
Some people recover relatively quickly.
Others may take considerably longer.
For a patient with established epilepsy, ask:
Is this normal for them?
Their usual recovery pattern can be extremely valuable information.
Recovery position
Once active convulsive movements have stopped, if the patient remains unconscious but is breathing normally, maintain their airway and use an appropriate recovery position where practicable.
Continue to monitor their breathing.
If they are not breathing normally, commence CPR and use the AED.
Protect the patient's dignity
A seizure can be an extremely vulnerable experience.
A patient may experience incontinence, confusion or embarrassment.
Remove unnecessary people from the surgery.
Speak quietly and reassuringly.
Allow the patient sufficient time to recover.
Do not immediately surround them with several members of staff asking questions.
One calm person communicating clearly may be much more helpful.
Look for injury
During recovery, assess for injuries that may have occurred during the seizure.
Consider:
Head injury
Facial injury
Soft-tissue injuries
Tongue or oral injury
Bleeding
Possible fractures or dislocations
If the patient has sustained a significant injury, seek appropriate medical assistance.
First seizure? Keep an open mind
A person experiencing seizure activity in a dental practice may not have epilepsy.
Seizures can occur for other reasons.
Potential causes include:
Hypoglycaemia
Cerebrovascular events
Head injury
Infection
Hypoxia
Metabolic abnormalities
Drug or medication-related causes
This is why the ABCDE assessment and medical history remain so important.
Do not become so focused on epilepsy that another serious cause is overlooked.
Teamwork and human factors
A seizure in a dental practice can attract everybody's attention very quickly.
Without leadership, six people can end up doing the same task while another important task is forgotten.
Allocate roles:
“You call 999.”
“You bring the emergency kit and oxygen.”
“You start timing.”
“You record our observations and treatment.”
“Stay with me and help assess the patient.”
This type of closed-loop communication helps reduce errors.
And remember:
It is entirely appropriate to say, “I need help.”
Even an experienced clinician may find a prolonged seizure challenging.
Before the emergency happens
Preparation should occur before the patient sits in the dental chair.
For patients with known epilepsy:
Review their medical history.
Ask about their usual seizure presentation.
Ask about recent seizure control.
Check their emergency care plan where applicable.
Clarify whether they carry rescue medication.
Know what their normal recovery looks like.
For the practice:
Check emergency equipment regularly.
Keep oxygen immediately available.
Ensure emergency medicines are in date.
Ensure staff understand the practice's medicines governance.
Practise seizure scenarios during annual medical-emergency training.
Annual medical-emergency CPD should be practical
Reading a seizure algorithm has value.
Actually practising the scenario as a dental team is far more revealing.
During scenario training you quickly discover questions such as:
Where is our oxygen?
Who calls 999?
Who knows where the midazolam is?
Where is the patient's medical history?
Can everybody use the oxygen equipment?
Can the team position the chair safely?
Who is actually watching the clock?
Who records what happened?
These may sound like simple questions.
During a real emergency, they matter enormously.
Keep seizure management simple and workable
When faced with a convulsing patient, remember:
STOP
Terminate dental treatment and remove hazards.
PROTECT
Protect the patient from injury without restraining them.
TIME
Record how long the seizure lasts.
AIRWAY & BREATHING
Assess using ABCDE as soon as practicable.
DO NOT PUT ANYTHING IN THE MOUTH
Protect — never restrain.
CARE PLAN
Follow the patient's individual emergency management plan where available.
MEDICATION
Use prescribed or authorised emergency medication only in accordance with the patient's plan, current medicines guidance and the dental team's competence and governance arrangements.
999
A convulsive seizure lasting 5 minutes or more is an emergency. Call for professional help.
MONITOR
Continue observation and reassurance throughout the recovery period.
Recognise, respond and reassess
The dental team does not need to become a specialist neurological service.
What the team needs is the ability to recognise that a medical emergency is occurring, keep the patient safe, provide effective first-line care and escalate appropriately.
In my experience, good emergency management is rarely about doing something complicated.
It is more often about doing the simple things well, remaining methodical and knowing when you need additional help.
Medical Emergencies CPD for Dental Teams
At Sussex First Aid Courses, our dental medical-emergency training includes practical scenario-based management of seizures and other emergencies that dental teams may encounter.
Training can cover:
Recognition of different seizure presentations
Tonic-clonic seizure management
Prolonged seizures and status epilepticus
ABCDE assessment
Emergency oxygen
Blood glucose assessment
Buccal midazolam awareness and medicines governance
Individual emergency care plans
Recovery and post-ictal management
Calling 999 and providing a structured handover
Emergency equipment familiarisation
Human factors and effective team communication
Our aim is not simply to help dental teams complete their annual CPD.
It is to help them feel prepared, confident and able to work effectively together when a real medical emergency happens.
About the author
Garry Perkins is a former paramedic with more than 35 years' experience in emergency care and the Director and Founder of Sussex First Aid Courses Ltd. He has extensive experience delivering medical-emergency CPD training to dental practices and healthcare teams.
Sussex First Aid Courses Ltd0800 069 9931 info@sussexfirstaidcourses.co.uk. www.sussexfirstaidcourses.co.uk
This article is for professional education and general awareness. Dental teams should refer to the current BNF/BNFC, NICE guidance, Resuscitation Council UK guidance, relevant dental medicines guidance, local policy, the Summary of Product Characteristics and individual patient emergency plans for current medication doses and administration requirements.
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