Online ISSN : 1687-8329

    




Quick Search 
 
Author  
Year    
Title  
Vol:  

 
 
July2010 Vol.47 Issue:      3 (Supp.) Table of Contents
Full Text
PDF


Management Challenges in Oromandibular Dystonia: The Role of Botulinum Toxin-A

Mohamed S. El-Tamawy, Hatem Samir

 

Department of Neurology, Cairo University; Egypt

 



ABSTRACT

Background: Oromandibular dystonia is a focal or segmental cranio-cervical dystonia, with diverse incapacitating clinical manifestations. Though botulinum toxin injection has emerged as an effective symptomatic treatment; yet, many unanswered questions are not addressed by the current available studies. Objective: To evaluate the efficacy of Botulinum toxin type A (BTX-A) treatment in patients with oromandibular dystonia. Methods: This prospective study included 13 patients with refractory oromandibular dystonia, who were followed up for 3 months. All patients were videotaped according to Dystonia Study Group Videotape examination protocol before and after injections. Injection technique was based on clinical observation coupled with electromyography. Primary outcome measure was the global impression scale (GIS), and secondary outcome measure was quantified according to Unified Dystonia Rating Scale (UDRS). Results: Patients showed improvement of both primary and secondary efficacy measures, maximum satisfactory responses were detected at the 4th week after injection. This improvement was maintained till the end of the study visits (12th week), and we could not detect any adverse events. Conclusion: BTX-A is considered an effective and safe treatment option for refractory OMD. [Egypt J Neurol Psychiat Neurosurg.  2010; 47(3): 347-354].

 

Correspondence to Mohamed S. El-Tamawy, 176 El-Tahrir St. – Babellouk – Down town, Cairo, Egypt.

E-mail: eltamawy@hotmail.com.





INTRODUCTION

 

Oromandibular dystonia (OMD) refers to involuntary spasms of masticatory, facial and lingual muscles leading to repetitive or sustained jaw opening, closure, deviation, or any combination of these movements1,2. Cardoso and Jankovic3 recognized several types of OMD that include; jaw closing dystonia (JCD), jaw opening dystonia (JOD), jaw deviation dystonia (JDD), lip and perioral dystonia, lingual dystonia, pharyngeal dystonia and a combination type.

The prevalence of OMD was estimated to be 68.9 cases/million persons4. It occurs either in isolation, or as part of a segmental cranial or a generalized dystonia5. It manifests as distorted oral position that may interfere with chewing, swallowing, and speaking. In addition, its appearance is often socially embarrassing and cosmetically disfiguring5,6.

The etiology of OMD is diverse; the leading cause of most cases is idiopathic (primary)7, but medication-induced8 and other secondary causes like peripheral trauma 5 and dental maneuver9 can be detected in some cases of OMD.

 

Associated findings in OMD can include trismus, facial grimacing, jaw protrusion, lip pursing, platysma contractions, and deviation or protrusion of the tongue6.

There are no commonly accepted diagnostic criteria of OMD nor well-defined management strategies10, the diagnosis of OMD and its types is clinically made and it might be misdiagnosed as temporomandibular joint syndrome, bruxism or psychological disturbance. Sensory tricks in OMD include touching the face or inserting something, such as tip of a pencil, into the mouth11,12.

Oromandibular dystonia is one of the most challenging forms of dystonia to treat13. Until the advent of botulinum toxin (BTX) therapy, systemic pharmacologic agents have been tried with limited efficacy; these include anticholinergics, benzodiazepines, baclofen, and tetrabenazine14. Also there are some limited experience of bilateral pallidal deep brain stimulation15; hence, BTX is now considered the treatment of choice for OMD, with robust improvement and very minimal untoward effects13,14,16,17.

The aim of this study is to assess the therapeutic effects of botulinum toxin – type A (BTX-A) therapy in cases of OMD.

 

METHODS

 

Study Protocol and Treatment. This was a prospective study that was conducted on 13 patients with oromandibular dystonia, who were followed up for at least 3 months to evaluate the therapeutic effects of botulinum toxin – A (BOTOX®, Allergen). Prior to the study commencement, all patients gave a written informed consent approved by Neurology Department Review Board in Cairo University.

Inclusion criteria. (1) Patients who were refractory to other treatment options; (2) symptoms that were sufficiently impairing patients’ quality of life or interfering with activities of daily living (ADL) or causing social embarrassment; (3) patients who are not previously subjected to BTX-A injection and (4) coherence of follow up visits.

Screening phase. Prior to the study, included patients were subjected to thorough physical and neurological examination. Assessment included a standardized questionnaire of the history of the presenting condition and its impact on ADL. Antecedent events and history of drugs intake were recorded. All of our included patients had their routine hematological and biochemical profile that included (complete blood count, blood sugar, liver and kidney function tests); and MRI brain.

Eight out of the included 13 patients (61.5%) had jaw closure dystonia (JCD), 4 (30.8%) has jaw opening dystonia (JOD) and one patient (7.7%) had mixed jaw movement dystonia (MJD), (a combination of jaw deviation and jaw opening).

Secondary etiologies were identified in 9 cases (69.2%); 2 (15.4%) patients developed symptoms following traumatic brain injury (TBI), one patient (7.7%) had tardive dystonia, following long history of dopamine receptor blocking drugs, one patient (7.7%) had peripheral dystonia following major dental maneuver, and 5 (38.4%) presumed to be related to Khat intake. The rest 4 patients (30.8%) have no apparent causes and presumed to have idiopathic focal, adult onset dystonia.

Evaluation phase. All patients were evaluated and videotaped once before injection and 2 weeks following injection, using digital camera (Sony, 7.2 mega pixels with double anti-blur technology); this was done after receiving a signed release form. The videotape protocol of mouth and lower face was done in a uniform manner adopted from Dystonia Study Group Videotape examination protocol 18 as follows; (1) At rest: close view of face for 30 seconds; (2) Activation procedures: (i) Tongue protrusion. (ii) Opening and closing mouth for 5 reps, and mouth deviation (iii) Speech (a) reading of a standardized passage, (b) sounds of “consonants: ‘tee’, ‘mee’, ‘la’, ‘ka’ 5 of each, (c) prolonged holding of note ‘eeeeeee’ for 5 seconds. (iv) Feeding solids/liquids if safe. Jaw and lower face scoring in relation to duration and motor severity was quantified according to Unified Dystonia Rating Scale (UDRS) (jaw and tongue region)19.

Injection Technique. Patients’ charts proposed by injectors were used for muscle selection based on clinical observation and palpation in palpable muscles coupled with monitoring muscle activity guided by electromyography (EMG) during injection sessions, and injection was done using an Allergan® EMG needle in muscles that show increased activity during particular movement or posture. According to Tintner, and Jankovic 20 ; masseters, temporalis and medial pterygoids represent potential injection targets for JCD; submentalis, anterior belly of digastric and lateral pterygoids for JOD; and contralateral lateral pterygoid for jaw deviation. The formulation and preparation of botulinum toxin type A (BOTOX®) was performed according to standard methods 17. Injected dosage regimen of BTX was guided by Baylor College of Medicine 17 and Columbia University College of Physicians and Surgeons 21. Finally the muscles injected and doses were recorded in patients’ charts.

Outcome Measures and Follow up. Primary outcome measure was the global impression scale (GIS) (0 = no improvement; 1 = mild improvement; 2 = moderate improvement; 3 = marked improvement) 6, while the secondary outcome measure was UDRS scoring system 19. Follow up visits were done at 2, 4, 8, and 12 weeks after injection to assess for efficacy variables and any reported possible adverse events. In each visit, results of injection were analyzed using videotaping in the same uniform manner.

Safety Measures. Any reported adverse event during the study was recorded and graded for severity (mild, moderate, or severe). Its relationship to study treatment was (none, possible, probable, or definite). A serious adverse event was defined as one that was fatal, life-threatening, permanently disabling, or required hospital admission.

Statistical Analysis. All statistical analyses were performed with the SPSS 15.0 software (SPSS Inc., Chicago, IL, USA). The standard descriptive statistics (e.g., mean, standard deviation) were used to summarize the data. For comparison of two variables measured in the same sample we customarily used the t-test for dependent samples at 5% level of significance (α = 0.05).

 

RESULTS

 

Epidemiological Characteristics

The current study included 13 patients (8 males “61.5%”, and 5 females “38.5%”), their age ranged from 32 to 52 years (mean, 41.46±6.28). The duration of OMD ranged from 1 to 6 years (mean, 3.31±1.65). Other types of dystonia and / or bruxism were noted in 7 patients (53.8%). Basic clinical characteristics are shown in Table (1).

 

Injection Techniques

Muscle selection for injection based on clinical assessment and electromyography to monitor muscle activity. Injected muscles for every patient were demonstrated in Table (2). The most frequently injected muscles were masseters and temporalis (8 injections for each). Doses of botulinum toxin (Botox®) for masseter (per side) ranged from 40 to 75 units (mean±SD; 61.25±11.57), and for temporalis doses ranged from 40 to 60 units (mean±SD; 46.88±8.84). The least frequently injected muscles were medial and lateral pterygoids (2 injections for each), with doses of (Botox®) ranged from 20 to 30 units (mean±SD; 25±7.07) for the former, and from 20 to 35 units (mean±SD; 27.5±10.61) for the later. For anterior digastric muscle (5 injections), doses ranged from 20 to 30 units (mean±SD; 25±3.53), and for submentalis (5 injections), doses ranged from 25 to 30 units (mean±SD; 29±2.24).

Outcome Measures

Primary efficacy variable (GIS) and secondary efficacy variable (UDRS) at 2, 4, 8, and 12 weeks interval following injection session are illustrated in Table (3).

Most of our patients have noted their improvement within the first week after injection.

 

UDRS (for oromandibular region)

Primary efficacy variables. Maximum satisfactory response was detected at 4th week assessment; 61.54% (8/13) of our patients showed marked improvement, 7 of them had JCD and one patient with JOD; whereas, 5 patients (38.46%) showed moderate improvement, one of them had JCD, 3 had JOD and one had MJD.

Secondary efficacy variables. Maximum improvement on UDRS scoring was detected also during visit 3 (4th week) (figure 1), and it was maintained till the end of study visits (12th week). When comparing between UDRS before injection and at the 4th week assessment, there was statistically significant improvement. Ratio statistics for UDRS (4th week) over UDRS (before injection) revealed 69.6% coefficient of variation (Table 4).

Safety Measures. No systemic adverse reactions were detected in our patients. Local adverse events were mild and transient; it included lip numbness (n=2) and pain at site of injection (n=5); both relieved within two days of injection.


 

Table 1. Basic clinical characteristics of patients with oromandibular dystonia.

 

 

Age/Sex

Type of OMD

Etiology

Duration (Years)

Other types of dystonia / Bruxism

UDRS (OMD)

1

32/M

JCD

Khat

2

Bruxism

5

2

46/M

JCD

-

5

Lower face grimacing, tongue and lip biting

5.5

3

52/F

JCD

TBI

2

 

3.5

4

42/M

JOD

Khat

3

Facial grimacing

6.5

5

33/M

JCD

-

4

 

5.5

6

38/F

JOD

-

6

 

7

7

47/M

JCD

Khat

4

Bruxism

6

8

36/M

JOD

Khat

5

Retrocollis, facial grimacing

7

9

39/F

MJD

T.D

2

JDD, JOD, facial grimacing, tongue protrusion, lip biting

7.5

10

50/M

JCD

DM

1

 

4

11

44/F

JOD

-

5

 

5

12

37/F

JCD

TBI

3

 

3.5

13

43/M

JCD

Khat

1

Facial grimacing, bruxism

6

DM  Dental Maneuver,  F female, JCD jaw closing dystonia, JOD jaw opening dystonia, M male, MJD jaw movement dystonia, TBI traumatic brain injury, TD Tardive Dyskinesia, UDRS Unified Dystonia Rating Scale

Table 2. Muscle selection for Botulinium toxin  injection in patients with oromandibular dystonia.

 

 

Type of OMD

Muscle selection for injection

1

JCD

Masseters, temporalis

2

JCD

Masseters, temporalis

3

JCD

Masseters, temporalis

4

JOD

Submentalis, anterior belly of digastrics

5

JCD

Masseters, temporalis, medial pterygoids

6

JOD

Submentalis, anterior belly of digastrics, lateral pterygoids

7

JCD

Masseters, temporalis, medial pterygoids

8

JOD

Submentalis, anterior belly of digastrics

9

MJD

Submentalis, anterior belly of digastrics, lateral pterygoids

10

JCD

Masseters, temporalis

11

JOD

Submentalis, anterior belly of digastrics

12

JCD

Masseters, temporalis

13

JCD

Masseters, temporalis

JCD jaw closing dystonia, JOD jaw opening dystonia, M male, MJD jaw movement

 

Table 3. Primary efficacy variable (GIS) and secondary efficacy variable (UDRS) in 2, 4, 8, and 12 weeks after Botulinium toxin injection in patients with oromandibular dystonia.

 

 

2 weeks assessment

4 weeks assessment

8 weeks assessment

12 weeks assessment

GIS

UDRS

GIS

UDRS

GIS

UDRS

GIS

UDRS

1

1

3.5

3

1.5

3

1.5

3

1.5

2

1

3.0

2

1.5

2

1.5

2

1.5

3

2

1.5

3

1.5

3

1.5

3

1.5

4

1

3.0

2

2.5

2

2.5

2

2.5

5

3

1.5

3

0.0

3

0.0

3

0.0

6

1

3.0

3

1.5

3

1.5

3

1.5

7

2

2.0

3

0.0

3

0.0

3

0.0

8

1

3.0

2

2.0

2

2.0

2

2.0

9

1

3.5

2

2.5

2

2.5

2

2.5

10

2

1.5

3

0.0

3

0.0

3

0.0

11

1

2.5

2

2.0

2

2.0

2

2.0

12

3

1.5

3

0.0

3

0.0

3

0.0

13

2

2.0

3

0.0

3

0.0

3

0.0

GIS global impression scale, UDRS Unified Dystonia Rating Scale

GIS – (0 – no improvement; 1 – mild improvement; 2 – moderate improvement; 3 – marked improvement)

 

Table 4. Comparison between UDRS at 4th week and UDRS before Botulinium toxin injection in patients with oromandibular dystonia.

UDRS (before injection) (mean±SD)

5.54±1.3

UDRS (4th week) (mean±SD)

1.15±1.0

P – value

0.000

Ratio statistics UDRS

(4th wk)/ UDRS

(before injection)

Coefficient of dispersion

0.541

Coefficient of variation (Median Centered)

69.6 %

SD  standard deviation, UDRS Unified Dystonia Rating Scale

 

Figure 1. Unified Dystonia Rating Scale (UDRS) at 4th week and before Botulinium toxin injection in patients with oromandibular dystonia

 

 


DISCUSSION

 

Oromandibular dystonia is a subset of movement disorders that involve masticatory apparatus and lower face leading to distorted orofacial posture and function13. Successful treatment with botulinum toxin has been demonstrated by many authorities16,17,21,22. In our patients series with refractory OMD; the primary efficacy variable was evaluated by the subjective global impression scale6; while secondary efficacy variable was quantified according to UDRS (jaw and tongue region), that was designed to eliminate subjective patient rating for speech and swallowing, and it showed excellent internal consistency (Cronbach’s α 0.93)19.

In the current series, secondary etiologies were detected in 9 patients, one of them had tardive dystonia. A focal cranio-cervical onset of most patients with tardive dystonia was emphasized by Tan and Jankovic11. Another patient developed his symptoms shortly after dental maneuver that temporally and anatomically related to dystonia with no additional precipitants. These criteria were used to diagnose peripherally induced OMD5,9. Two patients experienced their manifestations following traumatic brain injury. One of the most outstanding features in 5 of our patients with presumed secondary etiology was Khat (Cathaedulis) chewing. The Khat (Qat, Kat) plant contains psychoactive alkaloids with psychostimulant properties, and has been used for centuries as a widely-practiced recreational drug, mainly in some African and Middle Eastern countries especially in Yemen; where it can be considered as a lifestyle rather than addiction23. It consists of placing the green-leaved plant into the mucobuccal fold and chewing it for several hours, with subsequent release of psychoactive agents24. The relation between khat chewing and oromandibular dystonia was rarely addressed; however, Harms et al.25 proposed this relationship; and to our knowledge, there were no other studies that recognized it as a causal factor. Primary (idiopathic) focal, adult onset dystonia was presumed in the rest 4 patients.

Regarding the distribution of types of oromandibular dystonia in our cases, jaw closing dystonia is the most encountered type; same finding was detected in Columbia University College of Physicians and Surgeons (CPS) study 21 and Baylor College of Medicine (BCM)17 (Table 5).

During injection, we adopted Tintner and Jankovic20 techniques who emphasized that any given movement can be produced by several muscles. However; Tan and Jankovic17 in their long-term experience from 1988 through 1998 with BTX for OMD reported that the masseters and submental muscles were the only two muscles injected with BTX-A for JCD and JOD, respectively. Basically; in our study, the injection paradigm was manipulated according to clinical assessment and EMG guidance. However; Gelb et al.26 reported that it is not always possible to use electromyography since EMG recordings of all involved muscles in OMD are technically difficult and in some forms, the pattern of muscle involvement may change over time. However, Møller et al 27 documented better efficacy with longer response duration of BTX injections when guided by electromyography.

The mean doses of botulinum toxin (Botox ®) in masseters (per side) were 61.25±11.57 U and 29±2.24 U in submentalis. These doses are nearly similar to those used in BCM study17, in which mean doses of Botox (per side) were 54.2±15.2 U in masseters and 28.6±16.7 U in submental muscles. These doses are also similar to what had been used by Tan and Jankovic11. Regarding other injected muscles, we used higher mean doses than that were injected in the CPS study21 as shown in Table (6). Noteworthy, there are no clear guidelines for precise dosages for each injected muscle, and doses depend upon different methods of patient and muscle selection, methods of assessing severity and different injection techniques. In our study, higher mean doses were attributed to the markedly increased muscle activities that were detected during EMG assessment.

As regards, the overall effect of BTX-A injection, it was satisfactory for all included patients; with no response failure as assessed by GIS (primary outcome) and UDRS (secondary outcome). Complete objective improvement (UDRS score 0) was detected in 5/13 (38.46%) of our patients at 4th week following injection; all of them had JCD, and it was maintained till 12th week post-injection. Regarding the primary outcome, marked improvement was reported by 8 patients (61.54%), 7 of them had JCD; whereas, moderate improvement was recognized by the rest of our patients (38.46%), 3 of them had JOD.

The beneficial effects of botulinum toxin injection in OMD were addressed by numerous studies16,17,21,22,28, with a response rate reached up to 90-95%29. Our results showed better response of JCD to injection than that of JOD, a result that was previously found by Singer and Papapetropoulos10, and BCM17 who, showed moderate to marked improvement in 80% of patients with JCD and 40% of those with JOD.

Regarding response duration, in BCM study17 the mean response duration was 16.4±7.1 weeks, also Tan and Jankovic11 reported moderate functional improvement that was maintained for about 16 weeks. On the other hand, the immunogenicity of botulinum with subsequent non-responsiveness and treatment failure was recorded in rare reports of patients with OMD15,30, an issue that was not reported in our study.

In the current study, we could not detect any major adverse events. Comparing to the results of the BCM17 and CPS21 studies, they reported a higher frequency of adverse effects especially in BCM. In the current study, the EMG-guidance, injecting the most anterior portion of submental complex might explain absence of any possible major adverse events.

In conclusion, though BTX-A is considered a treatment of choice for OMD with satisfactory improvement and high safety and tolerability; yet, different methods of muscle selection, injection techniques, and objective responses evaluation account for results gaps along various studies.

 

 

[Disclosure: Authors report no conflict of interest]


 

 

Table 5. Distribution of oromandibular dystonia types in case series from BCM 17, CPS 21 and the current study.

 

Distribution

BCM

CPS

Current Study

Percent (number)

Percent (number)

Percent (number)

Jaw-closing dystonia

52.5% (85)

53.1% (51)

61.5% (8)

Jaw-opening dystonia

21.6% (35)

41.7 (40)

30.8% (4)

Jaw-deviation dystonia

1.9% (3) 24

5.2% (5)

 

Mixed jaw dystonia

24.0% (39)

 

7.7% (1)

 

Table 6. BTX-A doses in case series from CPS 21 and the current study.

 

CPS (BOTOX ® Units)

Current Study (BOTOX ® Units)

Temporalis

18.5 (2 – 75)

46.88 (40 – 60)

Medial pterygoid

16.3 (5 – 40)

25 (20 – 30)

Lateral pterygoid

15.9 (2.5 – 60)

27.5 (20 – 35)

Anterior digastrics

9.8 (3.75 – 30)

25 (20 – 30)


REFERENCES

 

1.        Jankovic J. Etiology and differential diagnosis of blepharospasm and oromandibular dystonia. In: Jankovic J, Tolosa E, editors. Advances in neurology. Facial dyskinesias. New York: Raven; 1988. pp. 103-16.

2.        Tolosa E, Marti MJ. Blepharospasm-oromandibular dystonia (Meige’s syndrome): clinical aspects. In: Jankovic J, Tolosa E, editors. Advances in Neurology. Facial dyskinesias. New York: Raven; 1988. pp. 173-84.

3.        Cardoso F, Jankovic J. Oromandibular dystonia. In: Tsui J, Calne D, editors. Handbook of Dystonia. New York: Marcel Dekker; 1995. pp. 181-90.

4.        Nutt JG, Muenter MD, Aronson A, Kurland LT, Melton LJ. Epidemiology of focal and generalized dystonia in Rochester, Minnesota. Mov Disord. 1988; 3: 188-94.

5.        Sankhla C, Eugene C Lai, Jankovic J. Peripherally induced oromandibular dystonia. J Neurol Neurosurg Psychiatry. 1998; 65: 722-8

6.        Papapetropoulos S, Singer C. Eating dysfunction associated with oromandibular dystonia: clinical characteristics and treatment considerations. Head Face Med. 2006; 2: 47.

7.        Burke RE, Fahn S, Jankovic J, Marsden CD, Lang AE, Gollomp S, et al. Tardive dystonia: late-onset and persistent dystonia caused by antipsychotic drugs. Neurology. 1982; 32: 1335-46.

8.        Jankovic J. Tardive syndromes and other drug-induced movement disorders. Clin Neuropharmacol. 1995; 18: 197-214.

9.        Thorburn DN, Lee KH. Oromandibular dystonia following dental treatment: case reports and discussion. N Z Denta J. 2009 Mar; 105(1): 18-21.

10.     Singer C, Papapetropoulos S. A comparison of jaw-closing and jaw-opening idiopathic oromandibular dystonia. Parkinsonism Relat Disord. 2006 Mar; 12(2): 115-8.

11.     Tan EK, Jankovic J. Tardive and idiopathic oromandibular dystonia: a clinical comparison. J Neurol Neurosurg Psychiatry. 2000. 68: 186-90.

12.     Jankovic J, Shannon KM. Movement disorders. In: Bradley WG, Daroff RB, Fenichel GM, Jankovic J, editors. Neurology in clinical practice. Vol. 6. Elsevier Inc.; 2006. pp. 2081-122.

13.     Schwartz M, Freund B. Treatment of temporomandibular disorders with botulinum toxin. Clin J Pain. 2002; 18(6 Suppl): S198-S203.

14.     Jankovic J. Medical therapy and botulinum toxin in dystonia. Adv Neurol. 1998; 78: 169-83.

15.     Markaki E, Kefalopoulou Z, Georgiopoulos M, Paschali A, Constantoyannis C. Meige's syndrome: A cranial dystonia treated with bilateral pallidal deep brain stimulation. Clin Neurol Neurosurg. 2010 May;112(4):344-6.

16.     Jankovic J, Orman J. Botulinum A toxin for cranial-cervical dystonia: a double-blind, placebo-controlled study. Neurology. 1987; 37: 616-23.

17.     Tan EK, Jankovic J. Botulinum toxin A in patients with oromandibular dystonia: long-term follow-up. Neurology. 1999; 53(9): 2102-2107.

18.     Burke RE, Fahn S, Marsden CD, Bressman SB, Moskowitz C, Friedman J. Validity and reliability of a rating scale for the primary torsion dystonias. Neurology. 1985; 35: 73-7.

19.     Comella CL, Leurgans S, Wuu J, Stebbins GT, Chmura T and The Dystonia Study Group. Rating Scales for Dystonia: A Multicenter Assessment. Mov Disord. 2003; 18(3): 303-12.

20.     Tintner R, Jankovic J. Botulinum Toxin Type A in the Management of Oromandibular Dystonia and Bruxism. In: Brin MF, Hallett M, Jankovic J editors. Scientific and Therapeutic Aspects of Botulinum Toxin. Lippincott Williams & Wilkins, Philadelphia, PA; 2002.

21.     Brin M, Blitzer A, Herman S, Steward C. Oromandibular dystonia: Treatment of 96 cases with botulinum A. In: Jankovic J, Hallett M, editors. Therapy with Botulinum Toxin. New York: Marcel Dekker; 1994. pp. 429-35.

22.     Gadhia K, Walmsley D. The therapeutic use of botulinum toxin in cervical and maxillofacial conditions. Evid Based Dent. 2009; 10(2): 53.

23.     Manghi RA, Broers B, Khan R, Benguettat D, Khazaal Y, Zulling DF. Khat use: lifestyle or addiction. J Psychoactive Drugs. 2009 Mar; 41(1): 1-10.

24.     El-Wajeh YA, Thornhill MH. Qat and its health effects. Br Dent J. 2009 Jan 10; 206(1): 17-21.

25.     Harms L. Spokert F., Alwarith H, Pragst F, Dognitz L. Oromandibular dyskinesia and dystonia with khat chewers. Poster Presentation (352). Drug-induced Movement Disorders Session. The movement disorder society’s 11th International congress of Parkinson's disease and movement disorders. June 3-7, 2007. Istanbul, Turkey.

26.     Gelb DJ, Yoshimura DM, Olney RK, Lowenstein DH, Aminoff MJ. Change in pattern of muscle activity following botulinum toxin injections for torticollis. Ann Neurol. 1991; 29: 370-6.

27.     Møller E, Bakke M, Dalager T, Werdelin LM. Oromandibular dystonia involving the lateral pterygoid muscles: four cases with different complexity. Mov Disord. 2007; 22: 785-90.

28.     Bhattacharyya N, Tarsy D. Impact on quality of life of botulinum toxin treatments for spasmodic dysphonia and oromandibular dystonia. Arch Otolaryngol Head Neck Surg. 2001;127: 389-92.

29.     Dutton JJ. Botulinum-A toxin in the treatment of craniocervical muscle spasms: short- and long-term, local and systemic effects. Surv Ophthalmol. 1996; 41: 51-65.

30.     Maestre-Ferrín L, Burguera J, Peñarrocha-Diago M, Peñarrocha-Diago M. Oromandibular dystonia: A dental approach. Med Oral Patol Oral Cir Bucal. 2009 Jan 1; 15(1): e25-7.


الملخص العربى

 

دور عقار البوتيولينوم في علاج الاختلالات العضلية في الفم والفكين

 

تعتبر الاختلالات العضلية في الفم والفكين من الاختلالات البؤرية التي يصاحبها أعراض اكلينيكية متعددة وتؤدي إلى خلل وظيفي معيق وتؤثر على الحياة اليومية للمريض من نواحي عدة كالكلام والأكل والبلع بالإضافة للإحراج الاجتماعي الذي يصاحبها. وبرغم التأثيرات الايجابية لعقار البوتيولينيوم الا ان كثيرا من الأطروحات لم يتم الاجابة الوافية عليها فيما أتيح من دراسات سابقة.

وتهدف هذه الدراسة البحثية إلى تقييم فعالية حقن البوتوكس في الاختلالات العضلية في الفم والفكين وذلك لتقدير الآثار المفيدة ودرجة الأمان لهذا العقار.

في هذه الدراسة التي اشتملت على 13 مريضا بالاختلالات العضلية المعيقة في الفم والفكين والتي صعب استجابتها للعلاج الدوائي، تم تصوير المرضى بناء على بروتوكول قياسي معاير وتم تقييم المرضى بواسطة (مقياس الانطباع الشامل) كمقياس للحصيلة الأولية بالاضافة الى (المقياس الموحد للاختلالات العضلية) كمقياس للحصيلة الثانوية. وقد تم حقن المرضى بواسطة جهاز رسم العضلات وقد تمت متابعة المرضى على مدار 3 أشهر.

وقد أظهرت النتائج تحسن كلا من المقياسين طوال فترة الدراسة، وقد بدأ التحسن في خلال الأسبوع الأول من الحقن، وظهرت أعلى نسب للتحسن في الأسبوع الرابع من الحقن، ولم نلحظ طوال فترة الدراسة أي آثار جانبية للحقن. ونستخلص من هذه الدراسة أن عقار البوتوكس مؤثر في علاج هذا النوع من الاختلالت الغضلية ويمكن احتماله بدون آثار جانبية.



2008 � Copyright The Egyptian Journal of Neurology,
Psychiatry and Neurosurgery. All rights reserved.

Powered By DOT IT