Oromandibular Dystonia: A Clinical Examination of 2,020 Cases

Progressive gray matter alterations in the Meige's syndrome and across sub-types

Meige Syndrome (MS) is a form of segmental dystonia, categorized into four subtypes. The common and specific neuro-mechanisms among these subtypes remain to be elucidated. Herein, 3D T1-weighted MRI images were obtained from 159 patients with primary MS (31 with MS-I, 92 with MS-II, and 36 with MS-IV). Voxel-based morphometry (VBM), surface-based morphometry (SBM), and causal structural covariance network (CaSCN) were utilized to investigate morphological variations and causal relationships in structural changes across subtypes. The study revealed a decremental trend in gray matter volume (GMV) of the right precentral gyrus (PreCG.R), right calcarine cortex (CAL.R), left parietal association cortex (PAL.L), and left hippocampus (HIP.L) from MS-I to MS-IV, which negatively correlated with BFMDRS scores. The progression of GMV atrophy was followed by a trajectory from HIP.L to PAL.L with disease duration and from PAL.R to HIP.L/CAL.L/PreCG.R with increasing BFMDRS scores. Support vector machine (SVM) analysis indicated that these GMV changes might be served as potential biomarkers for diagnosing MS subtypes, with areas under the curve (AUC) of 0.935, 0.864, and 0.882, respectively. The results suggest that the PreCG.R is a key region affected early in MS, with GMV reductions extending to other brain areas as the disease progresses, indicating a hierarchy of structural brain changes associated with disease duration in MS progression. Our study further provides evidence for the association of MS with extensive gray matter abnormalities.

Effect of Botulinum toxin on non-motor symptoms in adult-onset idiopathic focal/segmental dystonia

BACKGROUND

Non-motor symptoms, including depression, anxiety, sleep disturbances, pain and cognitive dysfunction, are a much more important predictor of quality of life than the severity of dystonia.

OBJECTIVES

To assess the effect of Botulinum toxin on non-motor symptoms and quality of life in patients with adult-onset idiopathic focal dystonia.

METHODS

Patients aged > 18 years diagnosed with idiopathic focal dystonia were recruited in this longitudinal cohort study. The severity of dystonia, non-motor symptoms, and quality of life were evaluated using the BFMDRS, DNMSQuest, and EQ-5D at baseline and 1 and 3 months after botulinum toxin.

RESULTS

65 patients were recruited with a median age of 59 years. Blepharospasm was the most common phenomenology. 49.2% of patients had depression at baseline assessed using the Beck Depression Inventory (BDI). There was a significant negative correlation between baseline BFMDRS, DNMSQuest, BDI, and HAM-A scores and quality of life, but there was no relation with the type of focal dystonia. The mean percentage improvement in the BFMDRS-M, BFMDRS-D, DNMSQuest, BDI, HAM-A and EQ-5D was 25%, 52%, 16%,20%,23% and 23%, respectively, at one month. There was no statistically significant correlation between percentage change in motor scores compared to depression and quality of life scores at one month.

CONCLUSION

Botulinum toxin improved motor and non-motor scores and quality of life at 1 and 3 months after botulinum toxin therapy. The motor scores did not correlate with depression and DNMSQUEST scores but showed a weak positive correlation with anxiety scores.

Treatment with OnabotulinumtoxinA for Oromandibular Dystonia: A Systematic Review and Meta-Analysis

Oromandibular dystonia (OMD) is a focal dystonia characterized by contractions of the masticatory, lingual, and other muscles of the stomatognathic system. We conducted a systematic review and meta-analysis to elucidate the impact and safety of botulinum toxin in OMD. The eligibility criteria were full-length original articles that provided data evaluating the efficacy and adverse effects of onabotulinumtoxinA injections in patients with OMD. PubMed and Embase were searched for articles published before 31 May 2023. We analyzed cases that showed a favorable response (>0% improvement), moderate or greater response (>50% improvement), and adverse effects. A fixed-model meta-analysis of 26 studies involving 1103 patients revealed that an overall favorable effect of onabotulinumtoxinA injection was observed in 96.2% (95% confidence interval [CI], 95-97.5%, p < 0.00001) of patients, with significant heterogeneity (p < 0.00001, I2 = 85%). A moderate response (>50% improvement) was observed in 88.9% of patients (95% CI, 87-90.8%, p < 0.00001) with significant heterogeneity (p < 0.00001, I2 = 85%). Adverse effects were detected in 17.8% of patients, and the most common event was dysphagia (10.1%). Our systematic review found that onabotulinumtoxinA injection was effective, with a low rate of side effects. Further randomized controlled trials are required to clarify the evidence-based efficacy and adverse effects.

Evaluating deep learning techniques for identifying tongue features in subthreshold depression: a prospective observational study

Objective

This study aims to evaluate the potential of using tongue image features as non-invasive biomarkers for diagnosing subthreshold depression and to assess the correlation between these features and acupuncture treatment outcomes using advanced deep learning models.

Methods

We employed five advanced deep learning models-DenseNet169, MobileNetV3Small, SEResNet101, SqueezeNet, and VGG19_bn-to analyze tongue image features in individuals with subthreshold depression. These models were assessed based on accuracy, precision, recall, and F1 score. Additionally, we investigated the relationship between the best-performing model's predictions and the success of acupuncture treatment using Pearson's correlation coefficient.

Results

Among the models, SEResNet101 emerged as the most effective, achieving an impressive 98.5% accuracy and an F1 score of 0.97. A significant positive correlation was found between its predictions and the alleviation of depressive symptoms following acupuncture (Pearson's correlation coefficient = 0.72, p<0.001).

Conclusion

The findings suggest that the SEResNet101 model is highly accurate and reliable for identifying tongue image features in subthreshold depression. It also appears promising for assessing the impact of acupuncture treatment. This study contributes novel insights and approaches to the auxiliary diagnosis and treatment evaluation of subthreshold depression.

Therapeutic Uses and Efficacy of Botulinum Toxin in Orofacial Medicine: A Dental Perspective

Botulinum neurotoxin (BoNT) is the exotoxin of Clostridium botulinum, a Gram-positive, spore-forming bacterium [...].

Clinical Neurology in Practice: The Tongue (part 2)

BACKGROUND

The tongue is an essential organ for the development of certain crucial functions such as swallowing and speech. The examination of the tongue can be very useful in neurology, as the various types of lingual alterations can lead to certain specific diagnoses, the tongue being a kind of 'mirror' of some neurological function.

REVIEW SUMMARY

To discuss the elements of clinical examination of the tongue in relation to neurological disorders. After reviewing the different superficial lesions of the tongue, we deal with various movement disorders of the tongue (fasciculations/myokimia, orolingual tremor, choreic movements of the tongue, dystonia of the tongue, lingual myoclonus, and psychogenic movements), disorders of taste and lingual sensitivity and lingual pain.

CONCLUSIONS

Examination of the tongue should not be limited to studying its motility and trophicity. It is equally important to check the sensory function and understand how to interpret abnormal movements involving the tongue. This study also aimed to demonstrate the importance of nonmotor tongue function in neurological practice.

Task-specific oromandibular dystonia secondary to chewing Khat (Catha edulis)- A series of 35 cases

BACKGROUND

The leaves of "Khat" (Catha edulis), an indigenous shrub of Yemen and Arabian Peninsula are habitually chewed by the inhabitants for psychostimulant properties.

OBJECTIVE

To describe a unique task specific Oro-mandibular dystonia (OMD) in Yemenese men, with a temporal association with chewing "Khat".

METHODS

Multicentric, retrospective analysis (2009-2020) of patients with OMD associated with "Khat" chewing, evaluating clinical features and response to Onabotulinum toxin A.

RESULTS

35 Yemenese men with a negative family history, normal neuroimaging mean age of 44.31(±3.21) years and prolonged (20.31 ± 3.27 years) history of chewing Khat, around 5.16(±0.80) hours/day presented with OMD-20 jaw opening, 13 jaw closing and 2 mixed affecting chewing (n = 6), speech (n = 3), or both (n = 26). Additional lingual dystonia was seen in five.

CONCLUSIONS

Chewing of khat is a repetitive task involving the jaw musculature and may be one of the causative factors of this task specific OMD. Recognition can prevent disability in these regions.

Anatomical categorization of isolated non-focal dystonia: novel and existing patterns using a data-driven approach

According to expert consensus, dystonia can be classified as focal, segmental, multifocal, and generalized, based on the affected body distribution. To provide an empirical and data-driven approach to categorizing these distributions, we used a data-driven clustering approach to compare frequency and co-occurrence rates of non-focal dystonia in pre-defined body regions using the Dystonia Coalition (DC) dataset. We analyzed 1,618 participants with isolated non-focal dystonia from the DC database. The analytic approach included construction of frequency tables, variable-wise analysis using hierarchical clustering and independent component analysis (ICA), and case-wise consensus hierarchical clustering to describe associations and clusters for dystonia affecting any combination of eighteen pre-defined body regions. Variable-wise hierarchical clustering demonstrated closest relationships between bilateral upper legs (distance = 0.40), upper and lower face (distance = 0.45), bilateral hands (distance = 0.53), and bilateral feet (distance = 0.53). ICA demonstrated clear grouping for the a) bilateral hands, b) neck, and c) upper and lower face. Case-wise consensus hierarchical clustering at k = 9 identified 3 major clusters. Major clusters consisted primarily of a) cervical dystonia with nearby regions, b) bilateral hand dystonia, and c) cranial dystonia. Our data-driven approach in a large dataset of isolated non-focal dystonia reinforces common segmental patterns in cranial and cervical regions. We observed unexpectedly strong associations between bilateral upper or lower limbs, which suggests that symmetric multifocal patterns may represent a previously underrecognized dystonia subtype.

The implementation of green supply chain management (GSCM) and environmental management system (EMS) practices and its impact on market competitiveness during COVID-19

Despite great academic interest in global green supply chain management (GSCM) practices, its effectiveness for environmental management systems (EMS) and market competitiveness during COVID-19 remains untapped. Existing literature suggests that a fundamental link between GSCM, EMS, and market competitiveness is missing, as supply management is critical to maintain market competitiveness. To fill this gap in the literature, this study examines whether environmental management systems influence the link between GSCM practice and market competitiveness in China. We also propose the articulating role of big data analytics and artificial intelligence (BDA-AI) and environmental visibility toward these associations in the context of the COVID-19 pandemic. We evaluated the proposed model using regression-based structural equation modeling (SEM) with primary data (n = 330). This result provides empirical evidence of the impact of GSCM on EMS and market competitiveness. Moreover, the results show that the BDA-AI and the environmental visibility enhanced the positive relationship between GSCM-EMS and EMS and market competitiveness in China. Recent research shows that supply chain professionals, policymakers, managers, and researchers are turning to formal EMS, BDA-AI, and environmental visibility to help their organizations achieve the competitiveness that the market indicates they need.

Adult-onset focal dystonias: To lump or split

The adult-onset focal dystonias are a group of clinically heterogeneous disorders that affect different regions of the body. Although they affect different regions with different clinical manifestations, there is evidence that etiopathogenesis is shared at the anatomical, physiological, and genetic levels. However, there is also evidence that etiopathogenesis varies. This chapter summarizes the evidence for lumping or splitting these apparently different clinical phenotypes. It also includes some potential explanations to explain the similarities and differences.

Oromandibular tics associated with Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is the most common cause of chronic tics. Patients with TS frequently manifest motor tics involving the eyes and face but oromandibular (OM) tics have been rarely studied.

MATERIALS AND METHODS

We reviewed the medical records and video-recordings of 155 consecutive patients with TS in our movement disorders clinic. In addition, we studied 35 patients with classic tardive dyskinesia (TD) and compared their clinical and demographic features with those with TS.

RESULTS

We identified 41 patients with OM tics (26.5%). Although patients with OM tics had a greater overall tic severity and higher frequency of.complex motor and phonic tics, in the bivariate analysis, only comorbid dystonic tics (P = 0.001), greater number of affected body parts (P = 0.012) and more frequent eye-rolling tics (P = 0.059) were included in the final regression model after controlling for other variables. When compared with patients with OM tics, patients with classic TD had more frequently masticatory movements (sensitivity, 0.86; specificity, 0.95), continuous tongue movements (sensitivity, 0.71; specificity, 1.0) and continuous OM movements (sensitivity, 0.4; specificity, 1.0).

CONCLUSIONS

OM tics are common and often troublesome or even disabling symptoms in patients with TS. They may be difficult to differentiate from TD, but the latter is typically manifested by continuous orolingual and masticatory movements.

Botulinum toxin for motor disorders

Botulinum neurotoxins are a group of biological toxins produced by the gram-negative bacteria Clostridium botulinum. After intramuscular injection, they produce dose-related muscle relaxation, which has proven useful in the treatment of a large number of motor and movement disorders. In this chapter, we discuss the utility of botulinum toxin treatment in three major and common medical conditions related to the dysfunction of the motor system, namely dystonia, tremor, and spasticity. A summary of the existing literature is provided along with different techniques of injection including those recommended by the authors.

Neurophysiological Basis of Deep Brain Stimulation and Botulinum Neurotoxin Injection for Treating Oromandibular Dystonia

Oromandibular dystonia (OMD) induces severe motor impairments, such as masticatory disturbances, dysphagia, and dysarthria, resulting in a serious decline in quality of life. Non-invasive brain-imaging techniques such as electroencephalography (EEG) and magnetoencephalography (MEG) are powerful approaches that can elucidate human cortical activity with high temporal resolution. Previous studies with EEG and MEG have revealed that movements in the stomatognathic system are regulated by the bilateral central cortex. Recently, in addition to the standard therapy of botulinum neurotoxin (BoNT) injection into the affected muscles, bilateral deep brain stimulation (DBS) has been applied for the treatment of OMD. However, some patients' OMD symptoms do not improve sufficiently after DBS, and they require additional BoNT therapy. In this review, we provide an overview of the unique central spatiotemporal processing mechanisms in these regions in the bilateral cortex using EEG and MEG, as they relate to the sensorimotor functions of the stomatognathic system. Increased knowledge regarding the neurophysiological underpinnings of the stomatognathic system will improve our understanding of OMD and other movement disorders, as well as aid the development of potential novel approaches such as combination treatment with BoNT injection and DBS or non-invasive cortical current stimulation therapies.

Effects of Botulinum Toxin Therapy on Health-Related Quality of Life Evaluated by the Oromandibular Dystonia Rating Scale

Oromandibular dystonia (OMD) refers to a focal dystonia in the stomatognathic system. Health-related quality of life (HRQoL) in isolated dystonia is associated with non-motor symptoms such as depression, anxiety, and pain, as well as motor symptoms. To evaluate HRQoL in patients with OMD, the therapeutic effects of botulinum neurotoxin (BoNT) therapy were assessed using a recently developed and validated comprehensive measurement tool called the Oromandibular Dystonia Rating Scale (OMDRS). Altogether, 408 patients (jaw closing dystonia, n = 223; tongue (lingual) dystonia, n = 86; jaw opening dystonia, n = 50; jaw deviation dystonia, n = 23; jaw protrusion dystonia, n = 13; and lip (labial) dystonia, n = 13) were evaluated at baseline and after the end of BoNT therapy or in a stable status. The total OMDRS score reduced significantly from 149.1 to 57.6 (p < 0.001). Mean improvement was 63.1%. All examiner-rated subscales (severity, disability, and pain) and patient-rated questionnaire scores (general, eating, speech, cosmetic, social/family life, sleep, annoyance, mood, and psychosocial function) were significantly lower at the endpoint than at baseline (p < 0.001). The BoNT injection had a highly positive impact on patient HRQoL, and the OMDRS could evaluate both motor phenomena and non-motor symptoms.

Diagnosis and classification of blepharospasm: Recommendations based on empirical evidence

BACKGROUND

Blepharospasm is one of the most common subtypes of dystonia, and often spreads to other body regions. Despite published guidelines, the approach to diagnosis and classification of affected body regions varies among clinicians.

OBJECTIVE

To delineate the clinical features used by movement disorder specialists in the diagnosis and classification of blepharospasm according to body regions affected, and to develop recommendations for a more consistent approach.

METHODS

Cross-sectional data for subjects diagnosed with all types of isolated dystonia were acquired from the Dystonia Coalition, an international, multicenter collaborative research network. Data were evaluated to determine how examinations recorded by movement disorder specialists were used to classify blepharospasm as focal, segmental, or multifocal.

RESULTS

Among all 3222 participants with isolated dystonia, 210 (6.5%) had a diagnosis of focal blepharospasm. Among these 210 participants, 34 (16.2%) had dystonia outside of upper face region. Factors such as dystonia severity across different body regions and number of body regions affected influenced the classification of blepharospasm as focal, segmental, or multifocal.

CONCLUSIONS

Although focal blepharospasm is the second most common type of dystonia, a high percentage of individuals given this diagnosis had dystonia outside of the eye/upper face region. These findings are not consistent with existing guidelines for the diagnosis and classification of focal blepharospasm, and point to the need for more specific guidelines for more consistent application of existing recommendations for diagnosis and classification.

A Clinical Approach to Focal Dystonias

Dystonia is a hyperkinetic movement disorder (HMD), characterised by sustained or intermittent involuntary muscle contractions resulting in abnormal postures and/or movements [1]. Although primary dystonia has an estimated prevalence of 16 per 100,000 [2], the diagnosis may be delayed, due to its clinical heterogeneity, the lack of objective biomarkers and the potential for pseudodystonic conditions to mimic it [1,3]. We provide an overview of the classification and common subtypes of focal dystonia, focusing on the clinical phenomenology and diagnosis.

Dystonia, chorea, hemiballismus and other dyskinesias

Hyperkinesias are heterogeneous involuntary movements that significantly differ in terms of clinical and semeiological manifestations, including rhythm, regularity, speed, duration, and other factors that determine their appearance or suppression. Hyperkinesias are due to complex, variable, and largely undefined pathophysiological mechanisms that may involve different brain areas. In this chapter, we specifically focus on dystonia, chorea and hemiballismus, and other dyskinesias, specifically, levodopa-induced, tardive, and cranial dyskinesia. We address the role of neurophysiological studies aimed at explaining the pathophysiology of these conditions. We mainly refer to human studies using surface and invasive in-depth recordings, as well as spinal, brainstem, and transcortical reflexology and non-invasive brain stimulation techniques. We discuss the extent to which the neurophysiological abnormalities observed in hyperkinesias may be explained by pathophysiological models. We highlight the most relevant issues that deserve future research efforts. The potential role of neurophysiological assessment in the clinical context of hyperkinesia is also discussed.

Botulinum Toxin Therapy for Oromandibular Dystonia and Other Movement Disorders in the Stomatognathic System

Various movement disorders, such as oromandibular dystonia, oral dyskinesia, bruxism, functional (psychogenic) movement disorder, and tremors, exist in the stomatognathic system. Most patients experiencing involuntary movements due to these disorders visit dentists or oral surgeons, who may be the first healthcare providers. However, differential diagnoses require neurological and dental knowledge. This study aimed to review scientific advances in botulinum toxin therapy for these conditions. The results indicated that botulinum toxin injection is effective and safe, with few side effects in most cases when properly administered by an experienced clinician. The diagnosis and treatment of movement disorders in the stomatognathic system require both neurological and dental or oral surgical knowledge and skills, and well-designed multicenter trials with a multidisciplinary team approach must be necessary to ensure accurate diagnosis and proper treatment.

Patient selection and injection techniques for botulinum neurotoxin in oromandibular dystonia

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Botulinum toxin is considered as the first-line therapy in oromandibular dystonia (OMD) by most experts and evidence-based literature.

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Oromandibular dystonia (OMD) can be classified into several subtypes so primary muscle involvements can be identified for botulinum toxin (BoNT) injections.

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This review article aims to provide a framework for practical clinical approaches in patients with OMD for BoNT injections.

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Careful stepwise planning is recommended to identify primary muscles responsible and employ a conservative approach to dosing titration.

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Treating physicians should be diligent to observe for adverse events as muscles involved in OMD are small, delicate and situated in close proximity.

Oromandibular dystonia (OMD) is a form of focal dystonia that involves the masticatory, lower facial, labial, and lingual musculature. It is a disabling disorder which had limited treatment options until the recent introduction of botulinum toxin (BoNT) as the recommended first-line therapy by most experts and evidence-based literature. Owing to the complex relationship between the muscles of mastication and surrounding muscles, there is a wide variety of dynamic clinical presentations, making clinical recognition and the corresponding approach to BoNT injection therapy difficult. In this review, the authors provide a framework for practical clinical approaches, beginning with the recognition of clinical subtypes of OMD (jaw-opening, jaw-closing, jaw-deviating, lingual, peri-oral, and/or pharyngeal dystonias), followed by patient selection and clinical evaluation to determine function interferences, with injection techniques illustrated for each subtype. Careful stepwise planning is recommended to identify the muscles that are primarily responsible and employ a conservative approach to dosing titration. Treating physicians should be diligent in checking for adverse events, especially for the first few injection cycles, as muscles involved in OMD are small, delicate, and situated in close proximity. It is recommended that future studies should aim to establish the clinical efficacy of each subtype, incorporating muscle targeting techniques and patient-centred outcome measures that are related to disturbed daily functions.