Abstract. OBJECTIVES Oromandibular dystonia (OMD) is a focal dystonia manifested by involuntary muscle contractions producing repetitive, patterned mouth. Oromandibular dystonia is a form of focal dystonia affecting the mouth, jaw and tongue, and in this disease it is hard to speak. It is associated with bruxism. Oromandibular dystonia causes spasms of the jaw, lips, and tongue muscles. This dystonia can cause problems with speech and swallowing.
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Oromandibular dystonia OMD is a rare focal neurological disorder that affects mouth, face, and jaws. This comprehensive literature review aimed to summarize the current evidence for etiology, diagnosis, and management of OMD and assess the possibility of dental origin of the disease and dental treatment plans for these patients. Different online databases namely PubMed, Google scholar, and Scopus were searched.
Out of articles, only 37 articles met the inclusion criteria. OMD can be caused or exacerbated through different dental treatments within which anyone is likely to be involved due to various reasons. Some novel methods employed to relieve this syndrome have led to certain cure or improvement of symptoms in several cases. OMD patients may refer to dentists with involuntary jaw movements and intraoral presentations.
Thus, the dentists should be aware of the symptoms and signs and refer the suspicious cases. Dentists should also be familiar with special considerations when managing OMD patients. Dystonia is the manifestation of involuntary lasting severe muscle contractions, which lead to rhythmic and atypical movements in different parts dostonia the body. Based on the affected area, dystonia can be anatomically categorized as focal affecting one or two parts of the bodysegmental, multifocal, and generalized.
It can also be categorized based on etiology. Primary dystonia is oromndibular or inherited; while, secondary dystonia advances after traumatic or surgical incidents, brain diseases, and medications. That type of dystonia that involves the oral cavity is described as oromandibular dystonia OMD. It is a rare focal neurological disorder that affects the lower facial muscles. It is characterized by repetitive or sustained involuntary prolonged spastic movements of the tongue, facial, oromabdibular masticator muscles.
oromandigular OMD is classified as jaw opening, jaw closing, jaw deviating, or lingual dystonia, or a combination of these. The prevalence of OMD has been reported to be as high as 6. The purpose of this study was to review the literature to assess the possibility of oromanvibular origin of the disease and dental treatment plans for these patients. The randomized controlled trials, case-control studies, case series, and single case reports containing a report on a clinical outcome were included.
In addition, the reference list of these articles was searched and those considered important were selected, as well. A comprehensive literature review was done from up to December Information collected from these 37 references was used to write the literature review.
The onset of symptoms is usually between the ages of 40 to 70 years and is more common in women. The symptoms only occur during activities such as speaking or mastication. Patients usually report triggers like stress, talking, chewing distoina and praying. Severity of symptoms and progression of the disease are more prominent in post-traumatic OMD than in primary OMD; however in the former, there is lower tendency to spread to contiguous or non- contiguous segments.
Specific activities or iromandibular stimuli, sometimes called sensory tricks are used to relieve the dystonia in OMD, but not in oromsndibular type of dystonia, such as cervical dystonia. Clinical presentations depend on the affected muscles, as well as the severity and distribution of OMD.
Dystonic spasms may be seen as nasal contractions, facial grimacing, lip pursing or sucking, bruxism, tongue dyskinesia, mouth corner retractions, and platysma spasms. Dysarthria or breathing difficulties are also reported rarely.
Etiology, Diagnosis and Management of Oromandibular Dystonia: an Update for Stomatologists
The difference between idiopathic sleep bruxism and OMD-induced bruxism is that the latter usually stops while sleeping. The prevalence of bruxism was higher in patients with cranial-cervical ddistonia.
Nevertheless, this difference was not significant between other diseased groups and the controls. Trismus, bruxism, and forceful involuntary jaw closure or temporomandibular joint TMJ dislocation can lead to trauma and damage of the oral cavity structures, dental restorations, and dentures, excessive dental wear, dental fractures, and trauma of the lips, gums, and tongue; while, jaw-opening dystonia may be associated with TMJ overload.
Muscle pain is usually associated with headache and facial pain as a result of dystonic activity and forceful contractions. However, most patients usually complain of muscular tension or tiredness, and pain was quite rarely reported. In a review by Blanchet et al. The dystonic activities are also associated with tooth loss and hyposalivation.
The mechanism and the cause of OMD are not well known. They reported temporal pattern of symptoms in patient and discussed the possible relationship between OMD and hormonal factors.
Peripherally-induced dystonia is usually not recognized, especially if the trauma is relatively trivial or the duration between the trauma and the onset of dystonia lasts longer than a few days. Despite the comprehensive document on peripherally-induced dystonia caused by injury to the affected body part, OMD from orofacial or dental procedures is scarcely reported in dental literature and neurological articles.
Although some cases of OMD have been reported after dental procedures, the causal relationship between these procedures and dystonia is still unclear. The patients had worn the dentures from a minimum of 1 to many years before noticing the abnormal movements. In 27 cases, the onset of the symptoms of OMD was related to a prior trauma of the face or mouth. Ten cases had family history of movement disorders, prior exposure to neuroleptic drugs, and associated dystonia affecting other regions.
Out of the 27 cases, 21 had prior dental procedures new ill-fitting full or partial dentures, root-canal therapy, gingivectomy, crowns, tooth removal, apicoectomy, osteotomy, or TMJ arthroscopic surgery. They concluded that different predisposing factors such as an associated movement disorder, family history of tremors, edentulous state, exposure to neuroleptic drugs, and peripheral nerve injury may contribute to the development of this movement disorder under some conditions or in certain vulnerable people; however, the relationship between them may be purely coincidental.
Jankovic and Van der Linden[ 20 ] assessed dystonia and tremor induced by peripheral trauma and predisposing factors.
They believed that tooth loss might trigger or worsen the dystonia. The dystonia spread very fast to involve the larynx, causing life- threatening laryngospasm which was treated by intubation. They concluded that patients with craniocervical dyskinesia might be at risk of developing severe and rapidly-spreading dystonia as a result of dental procedures.
What Is Oromandibular Dystonia? | Colgate® Oral Care
The complaint of ill-fitting full dentures in these patients should be taken seriously. Thorburn and Lee[ 15 ] discussed two OMD cases which occurred following extractions and full dentures. They suggested that the oromandibulwr procedure might have caused a triggering effect. Chidiac[ 10 ] described a case of OMD where an open lock of the mandible with a constant protrusive posture was persisting for more than 3 months.
In the reported case, spasm of lateral pterygoid muscles was revealed by neurologic evaluation, and medication and botulinum neurotoxins BoNT were utilized for relief. The author noted a huge loss of vertical dimension, which was restored through fabricating a provisional denture.
No detail was mentioned about the kind oromanvibular trauma and infection. The patient presented a 1-year history of involuntary retraction of lips while speaking, as well as dental implant surgery 6 months earlier.
There was neither medical history or medications, nor excessive use of perioral muscles due to the patient’s job or hobby. It was concluded that there might be a potential causal relationship between dental implants as peripheral injury and the development of OMD.
The diagnosis of OMD is clinical and complicated, since it presents in various forms and severities. It responds to no diagnostic medical test; hence, the diagnosis is based on individual information, history, neurological examination and confirmation by intramuscular electromyography EMG.
OMD patients are usually diagnosed by neurologists and are aware of their problems. The symptoms of OMD can get worse by emotional factors, which is among the reasons for the delayed diagnosis. Treatment of OMD is multi-disciplinary and varies from one patient to another.
There is inadequate evidence-based information about the efficacy of various medications currently being used for dystonia.
Physiotherapy is thought to promote brain re-wiring over time, so as to reduce the dystonic movements. This response oromandibuular well recognized in musicians. BoNT injection, a promising therapy for treating OMD, is a potent neurotoxin that blocks the release of acetylcholine at the presynaptic junction, resulting in temporary chemical denervation of skeletal muscles. BoNT injection is mainly technique- dependent.
Depending on the dose of therapy, jaw weakness or tremor, loss of smile, and dysphagia are expected as the side effects.
BoNT may be immunogenic, and some patients may develop secondary oromandibuoar responsiveness following multiple injections. MAB is a promising means of treating OMD, which is less expensive and cause no major side effect or resistance to the therapy. Treatment with medication, BoNT injection, and MAB therapy were not effective, and no significant enlargement of the bilateral coronoid process was observed. The jaw opening increased to 50mm in both patients.
What Is Oromandibular Dystonia?
The final coronoidotomy might be a useful treatment for patients with quite severe jaw-closing dystonia, where other conservative therapies are ineffective. Psychosocial and occupational therapy, support groups participation, cognitive behavioral therapy,[ 15 ] and deep brain stimulation surgery were also designed to reduce the hyperactivity of the muscles. Pallidotomy, thalamotomy, and focused ultrasound lesioning are the other options for patients with dystonia. According distonla Xu et al.
Although it did not work as rapidly as the local injection of Botox, their efficacy might be similar. Moreover, this treatment had no adversarial reaction. Searching the databases yielded a few articles disgonia OMD patients who received dental management. They made a suitable removable dental appliance to mimic the sensory trick.
Its positive effects might be due to the proprioceptive stimulation. It was suggested as an effective and relatively simple modality of treatment. Thorburn and Lee[ 15 ] oeomandibular intraoral sensory tricks in two cases of OMD following extractions and full dentures; therefore, acrylic shapes were made to mimic the tricks.
Arthroscopy and other TMJ surgeries yielded no useful result in some patients with peripherally-induced OMD, and even exacerbated the conditions in some others. Then, bilateral coronoidotomy and masseter muscle stripping was done in 18 cases. A mean overall improvement was detected in patients’ symptoms. Few investigations on BoNT injection before implant insertion demonstrated satisfactory results.
In particular, Sibley[ 36 ] reported a case of edentulous OMD restored with implants. The author suggested that the conventional techniques such as delayed loading, axial implant placement and BoNT injections could be used to reduce the dystonic movements with more predictable rehabilitation plan. Schneider and Hoffman[ 11 ] utilized prosthesis with minimal adjustments in recalls for a case of OMD.
The patient was pleased and able to maintain a comfortable facial position and her speech was intelligible. Complete resolution of symptoms while wearing the prosthesis was observed. The TMJ remained asymptomatic during this period.