Management of Movement Disorders Related to Orofacial Pain
Frank Lobbezoo
Pierre Blanchet
Gilles J. Lavigne
Hypokinetic (parkinsonian) movement disorders are commonly associated with sensorimotor oropharyngeal features. In addition, four main types of hyperkinetic movement disorders can be distinguished: (1) dystonia, (2) dyskinesia, (3) stereo-typies, and (4) bruxism. While these conditions are mainly diagnosed and managed by medical specialists, they consist of various repetitive, abnormal, involuntary movements that may affect the tongue, lips, and jaw. Orofacial pain is an under-recognized feature of several of these hypokinetic and hyperkinetic oral movement disorders. In this chapter, the management of the disorders associated with orofacial pain is presented, while their main motor and pain features, as well as their main management strategies, are summarized in Table 26-1.
| Table 26-1 Motor features, pain features, and management of movement disorders related to orofacial pain | |||
| Movement disorder | Motor features | Pain features | Management |
| Hypokinetic | |||
| Parkinson disease |
Rigidity, akinesia, bradykinesia, postural instability, resting tremor | General causes (eg, osteoarthritis, trauma), central causes (eg, impaired basal ganglia nociceptive processing) | Pharmacologic |
| Hyperkinetic | |||
| Dystonia | Involuntary mouth closure, opening, or deviation; blepharospasm; jerking; tremor; difficulty initiating movement | Atypical pain (eg, painful spasms, burning mouth syndrome, atypical facial pain, tension-type headache), biting injuries, temporomandibular pain | Pharmacologic (eg, botulinum toxin), occlusal splints, deep brain stimulation |
| Dyskinesia | Aimless, repetitive, irregular, sometimes patterned, involuntary movements of the labial, lingual, and jaw musculature | Generalized aching, orofacial pain, tongue pain, burning mouth syndrome | Pharmacologic (eg, botulinum toxin), deep brain stimulation |
| Stereotypies | Coordinated, repetitive, patterned movements producing grimaces, lip movements, biting, and chewing | In Gilles de la Tourette syndrome: musculoskeletal pain, neuropathic complications, self injuries | No treatment, or pharmacologic, possibly dental |
| Bruxism | Teeth grinding or clenching | Temporomandibular pain, tension-type headache | Occlusal splints, behavioral (counseling), pharmacologic (eg, clonazepam, clonidine) |
Parkinson Disease
Parkinson disease (PD) is the second most common neurodegenerative disorder in humans after Alzheimer disease, affecting 1% to 2% of the population after age 50. It results from cell loss, most noticeably dopaminergic neurons, in the nervous system. Its motor features include rigidity, akinesia (paucity of movement), bradykinesia (slowness of movement), and postural instability, often associated with resting tremor. Other sensory, autonomic, and cognitive manifestations, as well as anxiety and depression, are frequent. About 40% of PD patients experience body pain. The pain is commonly related to general causes such as osteoarthritis or trauma, but it may also be related to diseases of the central nervous system (CNS), including lesions of dopamine pathways and impaired basal ganglia nociceptive processing.1,2
Standard medical treatment for PD includes levodopa (a catecholamine precursor), dopamine D2 agonists, and enzyme blockers that optimize levodopa pharmacokinetics. Clinicians should be aware that recurrent pain in PD patients may reflect-fluctuations in drug response from one dose of levodopa to the next. Periods of low levodopa bio-availability are associated with return of motor symptoms, which may be accompanied by nonspecific oral pain or trigeminal neuralgia–like pain, the latter in absence of the usual trigger zones (see chapter 24). The pain episodes dissipate when the next dose of medication becomes effective. Other types of oral pain (eg, burning mouth syndrome [BMS], gum or jaw discomfort) do not clearly fluctuate with the motor condition.2 Dental status (eg, dentures, edentulism) does not appear to be of significance.
Dystonia
Orofacial dystonia (also known as Meige syndrome) is pro/>
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