Oromandibular Dystonia Revisited: A Review and a Unique Case

Oromandibular Dystonia: Clinical and Demographic Data from Eight-Two Patients

Objective

This study aimed to determine the demographic and clinical characteristics of patients with oromandibular dystonia (OMD).

Background

Dystonia is a movement disorder characterized by sustained involuntary muscle contractions that often cause abnormal postures. OMD is a rare focal dystonia that affects the tongue, jaw, and mouth. OMD, which is a rare public health problem, is often recognized as psychogenic and there are delays in its diagnosis and treatment.

Methods

Patients with OMD, both isolated and combined, followed at our Movement Disorders Outpatient Clinic between 2004 and 2021 were enrolled in this study. Age, sex, age at onset, and disease duration were recorded. The type of OMD, affected muscles, etiologies of accompanying neurological disorders, and treatment were noted.

Results

A total of 82 patients (44 women, 38 men) were included in this study. Among these, 39 patients had isolated OMD, and 43 patients had either segmental or generalized dystonia. Seven patients reported a family history of dystonia. Only nine patients reported a sensory trick. The average disease duration was 6.01 ± 3.73 (range, 1-29) years, and the average age at onset was 43.34 ± 18.24 (range, 1-78) years. The disease etiology was unknown (idiopathic) in most patients. Fifteen patients reported task-specific dystonia. The most common type of dystonia was jaw-opening dystonia.

Conclusion

OMD is focal dystonia that significantly affects the quality of life. This study adds more data to the literature by defining the clinical features of this rare disorder and draws attention to this neglected type of dystonia.

Movement Disorders Associated With Radiotherapy and Surgical Procedures

Occasionally, movement disorders can occur following interventional procedures including but not limited to radiotherapy, dental procedures, and cardiac, cerebral and spinal surgeries. The majority of these disorders tend to be unexpected sequelae with variable phenomenology and latency, and they can often be far more disabling than the primary disease for which the procedure was performed. Owing to poor knowledge and awareness of the problem, delays in diagnosing the condition are common, as are misdiagnoses as functional movement disorders. This narrative review discusses the phenomenology, pathophysiology, and potential treatments of various movement disorders caused by interventional procedures such as radiotherapy and neurological and non-neurological surgeries and procedures.

Movement disorders of the mouth: a review of the common phenomenologies

Movement disorders of the mouth encompass a spectrum of hyperactive movements involving the muscles of the orofacial complex. They are rare conditions and are described in the literature primarily in case reports originating from neurologists, psychiatrists, and the dental community. The focus of this review is to provide a phenomenological description of different oral motor disorders including oromandibular dystonia, orofacial dyskinesia and orolingual tremor, and to offer management strategies for optimal treatment based on the current literature. A literature search of full text studies using PubMed/Medline and Cochrane library combined with a manual search of the reference lists was conducted until June 2021. Results from this search included meta-analyses, systematic reviews, reviews, clinical studies, case series, and case reports published by neurologists, psychiatrists, dentists and oral and maxillofacial surgeons. Data garnered from these sources were used to provide an overview of most commonly encountered movement disorders of the mouth, aiding physicians in recognizing these rare conditions and in initiating appropriate therapy.

Drug-Induced Oromandibular Dystonia Presenting as Chronic Temporomandibular Joint Dislocation: A Rare Case Report

Approximately 15%-30% of patients receiving neuroleptic medication for a longer duration develop drug-induced dystonia. There are many variations of oromandibular dystonia (OMD), but the most common one is involuntary jaw-opening dystonia.

A rare case of chronic mandibular dislocation under long-term neuroleptic therapy is reported with clinical features, diagnosis, and various treatment modalities. Chronic dislocation leads to changes in associated soft tissue and muscles. Therefore, besides alteration of bony articular surfaces (eminectomy), soft tissue remodeling is required to achieve the perfect balance for temporomandibular joint (TMJ) working and occlusion.

Drug-induced orofacial dystonia presenting as chronic TMJ dislocation is rare. Therefore, in long-standing chronic dislocation cases during treatment, biomechanics of TMJ, its complex neurological system, and the physiology of the masticatory system should be considered to customize the treatment plan.

Oromandibular dystonia and temporomandibular disorders

BACKGROUND

The aim of this study was to characterize clinical features of patients with oromandibular dystonia (OMD) who had temporomandibular disorder (TMD) symptoms.

METHODS

A retrospective chart review of patients seeking treatment at a tertiary-level orofacial pain clinic from January 2015 through December 2020 was undertaken. The inclusionary criteria consisted of a diagnosis of OMD (International Classification of Diseases, Revision 10 code G24.4), which had been confirmed by a neurologist.

RESULTS

Eleven patients met the inclusion criteria. Focal dystonia and jaw deviation OMD were the most frequent diagnoses. A dental procedure was a triggering or aggravating factor in 36.4% of patients. All but 2 patients had a sensory trick, or tactile stimulus to a particular body part, and approximately one-half of the patients used an oral appliance as a sensory trick device. All but 1 patient had received a diagnosis of TMD, with myofascial pain of the masticatory muscles being the most prevalent diagnosis. Four patients had received a recommendation for orthodontic treatment. About one-half of the patients had undergone 1 or more invasive dental or maxillofacial surgical interventions to address their dystonia. Anxiety was the most common psychological comorbidity.

CONCLUSIONS

Because patients with OMD commonly experience TMD symptoms, they can receive a misdiagnosis of TMD while the OMD is overlooked.

PRACTICAL IMPLICATIONS

Owing to concomitant TMD symptoms, patients most often seek dental consultations and undergo treatments such as orthodontic interventions and temporomandibular joint surgeries. A dentist's competency in recognizing these patients can prevent unnecessary procedures and facilitate appropriate patient care.

Prevalence and clinical characteristics of patients with oromandibular dystonia seen in the orofacial pain clinic: a retrospective study

OBJECTIVE

The aim of this study was to describe the prevalence and clinical characteristics of patients with oromandibular dystonia (OMD) presenting to an academic orofacial pain clinic. OMD diagnosis was based on clinical signs and symptoms, presenting in varied forms and severities. Knowledge of clinical characteristics would help in early diagnosis and treatment of OMD.

STUDY DESIGN

In this retrospective study, we identified patients with OMD (International Classification of Diseases [ICD]-9 diagnostic code 333.82 and ICD-10 code G24.4) who presented at the clinic from October 2012 to December 2017. Additional selection criteria were age greater than 18 years and confirmation of OMD diagnosis with at least 1 follow-up visit.

RESULTS

Over a 5-year period, 22 patients with OMD were identified according to the ICD diagnostic codes, and of those, 6 patients met the selection criteria corresponding to a prevalence of 170 per 100,000 (95% confidence interval [CI] 70-390). The most common chief complaint was jaw pain (67%), and all patients had associated diagnosis of myofascial pain of masticatory muscles.

CONCLUSIONS

The prevalence of patients with OMD in an academic orofacial pain clinic is higher than previously reported in population-based studies. The presentation of OMD often includes temporomandibular disorders (TMDs), with involvement of various masticatory muscles.

Oromandibular Dystonia Related to Sertraline Treatment in a Child

In children, similar to adults, the agents that cause movement disorders are most commonly dopaminergic and antidopaminergic drugs. However, it is also known that selective serotonin reuptake inhibitors (SSRIs), which are frequently prescribed in child psychiatry practice, may rarely lead to tremor, akathisia, dystonia, dyskinesia, and parkinsonism. In this study, we report a rare side effect of SSRIs, namely oromandibular dystonia related to sertraline, in a pediatric patient who was diagnosed with posttraumatic stress disorder.

Oromandibular Dystonia: Demographics and Clinical Data from 240 Patients

Objective

To report demographic data from a large cohort of patients with oromandibular dystonia (OMD).

Methods

This is a retrospective review of patients with OMD referred to our institution between 1989 and 2015. Demographic (age of onset, gender, and familial history of dystonia) and clinical (type of OMD, associated dystonia, and etiology of dystonia) data were collected from a cohort of 240 individuals.

Results

The mean age of onset of OMD was 51.6 years old, with a female predominance (2:1). A family history of dystonia was found in 6 patients (2.5%). One hundred and forty-nine patients (62.1%) had the jaw-opening type of OMD, 48 patients (20.0%) had the jaw-closing type, and 43 patients (17.9%) had a mixed form of OMD. Lingual dystonia was also present in 64 (26.7%) of these patients. Eighty-two patients (34.2%) had a focal dystonia, 131 patients (54.6%) had a segmental dystonia, and 27 patients (11.3%) had a generalized dystonia. One hundred and seventy-one patients (71.3%) had idiopathic OMD.

Conclusion

OMD is a chronic and disabling focal dystonia. Our study found a prevalence of female patients, an onset in middle age and a predominantly idiopathic etiology. Unlike other studies, jaw-opening was found to be the most frequent clinical type of OMD.

Clinical Characteristics of Voice, Speech, and Swallowing Disorders in Oromandibular Dystonia

PURPOSE

To better define the clinical characteristics of idiopathic oromandibular dystonia, we studied voice, speech, and swallowing disorders and their impact on activities of daily living.

METHOD

Fourteen consecutive patients with idiopathic oromandibular dystonia and 14 matched, healthy control subjects were included in the study.

RESULTS

Dysarthria was the most common disorder and its characteristics varied from one patient to another. However, we frequently observed a hyperkinetic, dysarthric profile characterized by imprecise consonants, a rough voice, changes in intensity, and hypernasality. Dysphagia appeared to be slightly less frequent and less disabling than dysarthria. Most patients had difficulty swallowing solids, and the oral phase was particularly problematic. Dysarthria and dysphagia affected activities of daily living in general and the psychological/emotional domain in particular.

CONCLUSIONS

The characteristics of dysarthria in oromandibular dystonia vary significantly from one patient to another due to differences in the set of affected muscles, so each patient should receive a personalized rehabilitation program. Dysarthria was the most prominent symptom, although spasmodic dysphonia was more frequent than expected. Further laboratory-based studies are needed to clarify the mechanisms and consequences of dysphagia in oromandibular dystonia.

Therapeutic applications of botulinum neurotoxins in head and neck disorders

Objective

The aim of this article is to review the mechanism of action, physiological effects, and therapeutic applications of botulinum neurotoxins in the head and neck area.

Study design

An extensive literature search was performed using keywords. The resulting articles were analyzed for relevance in four areas: overview on botulinum neurotoxins, the role of botulinum neurotoxins in the management of salivary secretory disorders, the role of botulinum neurotoxins in the management of facial pain, and the role of botulinum neurotoxins in head and neck movement disorders. Institutional review board approval was not needed due the nature of the study.

Results

Botulinum neurotoxin therapy was demonstrated to be a valuable alternative to conventional medical therapy for many conditions affecting the head and neck area in terms of morbidly, mortality, and patient satisfaction with treatment outcomes.

Conclusion

Botulinum neurotoxin therapy provides viable alternatives to traditional treatment modalities for some conditions affecting the head and neck region that have neurological components. This therapy can overcome some of the morbidities associated with conventional therapy. More research is needed to determine the ideal doses of botulinum neurotoxin to treat different diseases affecting the head and neck regions.

Botulinum toxin for treating muscular temporomandibular disorders: a systematic review

OBJECTIVE: This study, through a systematic literature review, aims to analyze the effectiveness of Botulinum Toxin as a treatment for masticatory myofascial pain and muscles temporomandibular disorders (TMD). METHODS: Survey in research bases: MEDLINE, Cochrane, EMBASE, Pubmed, Lilacs and BBO, between the years of 1966 and April 2011, with focus in randomized or quasi-randomized controlled clinical trials, blind or double-blind. RESULTS: After applying the inclusion criteria, 4 articles comprised the final sample: 3 were double-blind randomized controlled clinical trials and 1 was single-blind randomized controlled clinical trial. CONCLUSIONS: According to the literature, there is lack of evidence about the real effectiveness of botulinum toxin in the treatment of masticatory myofascial pain and muscular TMD. Thus, further randomized controlled clinical trials, with representative samples and longer follow-up time, to assess the real effectiveness of the technique are needed.

Oromandibular dystonia: a clinical report

Oromandibular dystonia (OMD) consists of prolonged spasms caused by contraction of the muscles of the mouth and mandible and involves the muscles of mastication, facial expression, tongue, and eye lids. A multidisciplinary treatment approach is presented including the fabrication of a dental prosthesis to reduce/eliminate the symptoms of OMD. Etiology and treatment issues are discussed, emphasizing the importance of an interdisciplinary treatment approach.

Palatal myoclonus associated with orofacial buccal dystonia

Palatal myoclonus is a rare condition in which there are rhythmic jerky movements of the soft palate and sometimes of the other muscles innervated by the brainstem A particularly annoying symptom is a rhythmic clicking sound in the ear due to the opening and closing of the Eustachian tube. Orofacial buccal dystonia is a focal dystonia with sustained spasms of the masticatory, facial or lingual muscles. The frequent symptoms of this disease have mainly been reported to be involuntary and possibly painful jaw opening, closing, deflecting and retruding, or a combination of the above. However, the subtle and unnoticeable involuntary movement of multiple facial muscles, which might be an infrequent symptom of orofacial buccal dystonia, makes this disease hard to diagnose. Understanding the functional orofacial anatomy that is responsible for the clinical signs and symptoms is necessary for making a proper diagnosis. Here we report on a rare case of palatal myoclonus that was associated with orofacial buccal dystonia, and such a case has not been previously reported. We describe the diagnostic approach and excellent treatment results after Botulinum toxin A (Dysport) injection and proper counseling.

Adult-onset dystonia

Dystonia is defined as involuntary sustained muscle contractions producing twisting or squeezing movements and abnormal postures. The movements can be stereotyped and repetitive and they may vary in speed from rapid to slow; sustained contractions can result in fixed postures. Dystonic disorders are classified into primary and secondary forms. Several types of adult-onset primary dystonia have been identified but all share the characteristic that dystonia (including tremor) is the sole neurologic feature. The forms most commonly seen in neurological practice include cranial dystonia (blepharospasm, oromandibular and lingual dystonia and spasmodic dysphonia), cervical dystonia (also known as spasmodic torticollis) and writer's cramp. These are the disorders that benefit most from botulinum toxin injections. A general characteristic of dystonia is that the movements or postures may occur in relation to specific voluntary actions by the involved muscle groups (such as in writer's cramp). Dystonic contractions may occur in one body segment with movement of another (overflow dystonia). With progression, dystonia often becomes present at rest. Dystonic movements typically worsen with anxiety, heightened emotions, and fatigue, decrease with relaxation, and disappear during sleep. There may be diurnal fluctuations in the dystonia, which manifest as little or no involuntary movement in the morning followed by severe disabling dystonia in the afternoon and evening. Morning improvement (or honeymoon) is seen with several types of dystonia. Patients often discover maneuvers that reduce the dystonia and which involve sensory stimuli such as touching the chin lightly in cervical dystonia. These maneuvers are known as sensory tricks, or gestes antagonistes. This chapter focuses on adult-onset focal dystonias including cranial dystonia, cervical dystonia, and writer's cramp. The chapter begins with a review of the epidemiology of focal dystonias, followed by discussions of each major type of focal dystonia, covering clinical phenomenology, differential genetics, and diagnosis. The chapter concludes with discussions of the pathophysiology, the few pathological cases published of adult-onset focal dystonia and management options, and a a brief look at the future.