Abstracts

Tooth-brushing epilepsy is a very unusual form of reflex epilepsy, provoked by the act of tooth brushing.
We report a 57-year-old patient with intractable partial epilepsy in which seizures were induced not only by tooth brushing, but also by seeing or thinking to a toothbrush or toothpaste. Patient was referred to our Epilepsy Unit for long-term video-EEG recordings. Various types of cognitive tasks were performed to provoke seizure. The first seizures started at the age of 50. The patient noted that several activities related to a toothbrush frequently provoked the seizures (approximately 40 % of the seizures). Seizures could be provoked by (i) tooth-brushing, especially in the morning, or (ii) seeing a toothbrush or toothpaste (its own, or seen on TV, in supermarket), especially if these objects were seen in an inadequate location, or (iii) thinking to toothbrush or toothpaste. No other trigger factor was identified.
The seizure started with the pleasant feeling to be somewhere else during few seconds, then the patient felt anxious and a loss of consciousness with oral automatisms may occur.
Brain MRI was normal, except for few hypersignals in the white matter and moderate enlargement of the lateral ventricles.
During the video-EEG monitoring, four seizures were recorded. Two were elicited by tooth brushing in the bathroom, while the patient was alone. Several tests failed to provoke a seizure: tooth-brushing in front of the video camera, presentation on a TV screen of various pictures related to the toothbrush, researching a toothbrush hidden in the patient[apos]s room. On the other hand, two seizures were elicited by the evocation of (i) the TV advertisement that recently had provoked a seizure (a man with a toothbrush), and (ii) a place related to seizures that the patient avoided.
The EEG showed a left temporal lobe onset of the seizures, and interictal epileptic spikes in the same area. This is, to our knowledge, the first report of reflex epilepsy in which seizures could be provoked by thinking to a toothbrush. This case differs from four previous patients reported with tooth-brushing epilepsy, for which hyperexcitability of the suprasylvian operculum was suggested. EEG and clinical data of our patient suggest a left temporal epileptogenic focus. We hypothesize that this epileptogenic zone may be closely related to the neurons responsible for the mental representation of the toothbrush in the temporal lobe.