Epilepsia, 47(11):1971–1973, 2006 Blackwell Publishing, Inc. C  2006 International League Against Epilepsy Toothbrush-Thinking Seizures Vincent Navarro, Claude Adam, Claire Petitmengin, and Michel Baulac Epilepsy Unit, AP-HP, Piti´ e-Salpˆ etri` ere Hospital, Paris, France Summary: Seizures associated with toothbrushing have been reported in patients with precentral or postcentral partial epilepsy. Seizures precipitated by thinking have been described in patients with idiopathic generalized epilepsy. We report a pa- tient with intractable partial epilepsy in which seizures were induced both by toothbrushing, and by seeing or thinking about toothbrush and toothpaste. Video-EEG analysis revealed a left temporal lobe origin for these reflex seizures. We discuss how complex multimodal stimuli may trigger these reflex seizures. Key words: Reflex seizure—Temporal lobe epilepsy—Partial epilepsy—Toothbrushing. Toothbrushing epilepsy is an unusual form of reflex epilepsy provoked by the act of toothbrushing. Seizures which began by facial motor or sensory manifestations and originated from the precentral or postcentral gyrus have been described in four distinct reports (Holmes et al., 1982; O’Brien et al., 1996; Koutroumanidis et al., 2001; Kanemoto et al., 2001). A medial temporal lobe origin was noted in another case associated with ictal orgasms (Chuang et al., 2004). Thinking epilepsy is an- other rare form of epilepsy induced by specific cognitive tasks mainly occurring in idiopathic generalized epilepsies (Ferlazzo et al., 2005). Partial epilepsies are exception- ally triggered by the action of mind (Martinez et al., 2001). Here, we report the case of a man with intractable partial epilepsy in which seizures were induced either by tooth- brushing, or by seeing or thinking of toothbrush or tooth- paste. CASE REPORT A 57-year-old right-handed man was referred to our Epilepsy Unit with intractable epilepsy. Treated at refer- ral with carbamazepine (800 mg/day), topiramate (250 mg/day), lamotrigine (500 mg/day), and clonazepam (0.5 mg/day) he presented one seizure per week. The first seizures occurred at the age of 50. The patient noted that toothbrushing and related activities provoked about 40% Accepted June 20, 2006. Address correspondence and reprint requests to Dr. Vincent Navarro, Epilepsy Unit, Piti´ e-Salpˆ etri` ere Hospital, 47-83 boulevard de l’Hˆ opital, 75013 Paris, France. E-mail: vincent.navarro@psl.aphp.fr doi: 10.1111/j.1528-1167.2006.00822.x of the seizures. Seizures were provoked by (i) toothbrush- ing, especially in the morning, without a specific oral trig- ger zone, or (ii) seeing a toothbrush or toothpaste (in the home, on TV or in shops), especially in an unexpected location, or (iii) thinking of toothbrush or toothpaste. No other trigger factor was noted, but according to the pa- tient, seizures could be prevented by the cold contact of the ground on his feet during toothbrushing. Spontaneous and reflex seizures usually started with the pleasant feeling that the patient was elsewhere for a few seconds. This feeling changed to an anxiety with occa- sional loss of consciousness and oral automatisms. The medical history was unremarkable, with no family history of epilepsy. Physical, oral, and neurological exam- inations were normal. The brain MRI was normal, except for few increased T2 signals in white matter and moderate enlargement of the lateral ventricles. During video-EEG monitoring, four seizures were recorded during 7 days. Two were elicited by different mental events. The first was the recollection of a TV ad- vertisement, which included a man cleaning a shotgun with a toothbrush, which had provoked a seizure previ- ously. The patient described that the recollection occurred suddenly and spontaneously and seemed to occupy all his visual field before he lost consciousness. The second men- tal event was the remembrance of a place where seizures previously occurred. Two other seizures were elicited by toothbrushing while the patient was alone in the bathroom. One of them was voluntarily elicited by the patient. During toothbrushing, vision became blurred, some images were recalled and consciousness was lost. Several tests did not provoke seizures. They included toothbrushing during video monitoring, presentation of 1971