An 84-year-old female patient was receiving outpatient department follow-up for left hemiplegia which had developed from a right middle cerebral artery (MCA) infarction. The patient had two old cerebral vascular attacks in her medical history, and magnetic resonance imaging (MRI) taken at that time seem like a recent small infarction in the right parietal lobe, a chronic infarction in the bilateral basal ganglia (BG) and left cerebellar hemisphere (Fig. 1A). She was diagnosed with diabetes mellitus (DM) and hypertension (HTN), for which she was receiving oral medication, and had worn dentures for 5 years. She came to the hospital complaining about orofacial dyskinesia symptoms, as her jaw had been moving 2–3 Hz side-to-side for a month. She also suffered from an orofacial cavity ulcer, as the dentures were not fixed due to the dyskinesia, and from a related eating disorder. The dopaminergic agents; ropinirole (Requip^®; GlaxoSmithKline, Research Triangle Park, NC, USA) 2 mg #2 and amantadine (PK-merz^®; Ursapharm Arzneimittel GmbH Industriestrasse, Saarbrücken, Germany) 200 mg #2 were prescribed and taken for a week with no improvement. After explaining the treatment to the patient and guardians and obtaining their consent, metoclopramide (Macperan^®; Hospira, Inc., Lake Forest, IL, USA) 5 mg 6T #3 was administered. Two hours after administration, the symptoms started to improve and after taking the medication for approximately two weeks, the dosage was reduced to 3T #3. However, the symptoms returned (although at a decreased frequency), and the dosage was therefore raised back to 6T. The frequency of the symptoms has now significantly decreased, and the patient and guardians report that her meal intake has increased as the dentures are now well secured. There have been no particular complications.

A 64-year-old male patient had been receiving follow-up in the clinic after hospitalization in the Rehabilitative Medicine Department for left hemiplegia caused by the right MCA infarction four years prior. Brain MRI taken at that time seemed like a recent infarction in right MCA territory and chronic infarctions in bilateral BG, periventricular white matter, cerebellar hemispheres and left pons (Fig. 1B). The patient came to the hospital as he started experiencing orofacial dyskinesia symptoms, with the jaw moving 2–3 Hz side-to-side, and a loss of appetite for two months. His medical history revealed that he had HTN and DM and had been using dentures since 2008. He had been taking risperidone (Risperdal^®; Ortho-McNeil-Janssen Pharmaceuticals, Inc., Titusville, NJ, USA) 0.5 mg for three years for behavioral problems and after emerging oral dyskinesia, stopping risperidone. Having explained the treatment to the patient and guardians and obtained their consent, we started using metoclopramide (Macperan^®; Hospira, Inc.) 5 mg 6T #3. The symptoms began to improve two hours after administration, and prescription of the medication has been maintained for five months.

An 84-year-old male patient had been receiving follow-up in the clinic after hospitalization in the Rehabilitative Medicine Department for quadriplegia caused by “top of the basilar” syndrome, which had occurred two years prior. He had HTN, DM, old tuberculosis, hyperlipidemia, hepatocellular carcinoma, chronic renal failure, and benign prostatic hyperplasia in his medical history, and had been using dentures for five years. For three months, he had been experiencing symptoms of orofacial dyskinesia by which his jaw moved from side to side, which had caused an eating disorder and subsequent poor food intake, resulting in a weight loss of 5 kg. Brain MRI revealed chronic infarctions in bilateral posterior cerebral artery territories, cerebellums, frontal lobes, left BG, and right midbrain (Fig. 1C). And, he had been taking risperidone 1 mg for unstable mood three months before orofacial dyskinesia began. Having explained the treatment to the patient and guardian and obtained their consent, we started to use metoclopramide (Macperan^®; Hospira, Inc.) 5 mg 6T #3. The symptoms of orofacial dyskinesia began to improve two hours after administration of the medication. After taking the medication for two weeks, the patient is now free of symptoms and his meal intake has increased, without particular complications from the medication (Supplementary Video 1).

A 78-year-old female patient received decompressive craniectomy from the Neurology Department for a right cerebellar infarction with hemorrhagic transformation which had appeared 1 month prior. She was transferred to the Rehabilitative Medicine Department and received rehabilitation treatment. Brain MRI revealed a recent infarction in the right posterior inferior cerebellar artery territory and chronic infarctions in the right periventricular white matter and right cerebellar hemisphere (Fig. 1D). She had a history of taking medication for HTN and atrial fibrillation, and not taking dopamine-related medication such as antipsychotics, and had been using dentures for five years. After transferring to the Rehabilitative Medicine Department, symptoms of orofacial dyskinesia, with the jaw moving about 3–4 Hz side-to-side, were observed in the daytime, although they disappeared when the patient slept. When feeding orally, most of the food was spilled out and she had difficulty swallowing because of the dyskinesia symptoms; hence, nasogastric tube feeding was applied. When a videofluoroscopic swallowing study (VFSS) was performed, it was observed that due to the continuous orofacial dyskinetic movement of the mandible and tongue, the bolus did not move to the pharyngeal phase from the oral phase, causing an anterior spill. Metoclopramide (Macperan^®; Hospira, Inc.) 5 mg 6T #3 was used, and 1 hour later the symptoms had decreased and a symptom-free state maintained from the next day on (Supplementary Video 2). Following discharge from the hospital, the abnormality in the oral phase disappeared on the VFSS, and the patient is now taking general diet orally.

A 75-year-old female patient had experienced bilateral cerebellar infarction in October 2011, and after that she had experienced left MCA territory infarction 3 years later (Fig. 1E). Since then, she had received rehabilitation treatment in several hospitals. She had a history of receiving total abdominal hysterectomy, cholecystectomy, and left renal mass removal, and was taking warfarin for a diagnosis of atrial fibrillation. She had no history of using dentures and dopamine related medication. Following hospitalization, orofacial dyskinesia symptoms, with the jaws moving left to right, were observed in the daytime, although they disappeared when the patient slept. In the VFSS test, the bolus did not move from the oral phase due to the continuous dyskinetic movement, and the patient was therefore fed by nasogastric tube feeding. Having explained the treatment to the patient and guardian and obtained their consent, metoclopramide (Macperan^®; Hospira, Inc.) 5 mg 6T #3 was administered. However, there was no improvement in the symptom, and the dosage was reduced to 5 mg 4T #2. After two days, the oral dyskinetic movement had been significantly reduced, and the patient later became-symptom free, so that an oral diet was slowly resumed. The dyskinetic movement of the tongue and jaws had disappeared but the movement of the head from left to right was observed. There were no other observations of complications from the medication.

A 48-year-old male patient was diagnosed with quadriplegia from pontine intracerebral hemorrhage (Fig. 1F). He had a history of HTN, hepatitis B virus carrier, and liver cirrhosis, and had not used dentures before. He also did not take antipsychotics, antiparkinsonism agents, antiemetics, anticonvulsants, etc. which are known to be associated with orofacial dyskinesia. Two weeks before the hospitalization, he began to manifest symptoms of orofacial dyskinesia in the daytime, which disappeared when he slept. The dyskinesia symptoms usually worsened with increased emotional stress. The patient was on a gestational diabetes diet, and orofacial dyskinesia was not observed while feeding. Having explained the treatment to the patient and guardian and obtained their consent, metoclopramide (Macperan^®; Hospira, Inc.) 5 mg 3T #3 was administered. Afterward, the orofacial dyskinesia symptoms observed in the daytime decreased significantly, and there were no particular side effects.

An 88-year-old female patient came to the rehabilitative medicine clinic complaining about poor oral intake and gait disturbance. The patient had developed right hemiplegia from the stroke 20 years prior and brain computed tomography revealed chronic infarctions in the left frontal lobe and bilateral BG (Fig. 1G). She had been able to walk despite a lower extremity equinovarus deformity, however, due to recent general deterioration, she was only able to sit alone. When the patient was awake, she thrust her tongue out 1–2 times per second and spat out more food than she swallowed when eating due to the tongue thrust movement. Because of the orofacial dyskinesia, her dentures were not secured, so that she had to continually re-insert them with her hands. She had taken risperidone 0.5 mg and escitalopram (Lexapro^®; Forest Laboratories LLC, St. Louis, MO, USA) 10 mg about for 4 years in the psychiatric department, but stopped risperidone after emerging orofacial dyskinesia. Her symptoms started to improve after the first administration of metoclopramide (Macperan^®; Hospira, Inc.) 5 mg 3T #3, so that the irregular tongue thrusting was reduced to once every 3–4 seconds, and she was able to keep her mouth closed when instructed. According to reports from her guardian, the amount of spilled food had decreased and the meal intake increased. Later, complete remission of the symptoms was observed after the dosage was increased to 5 mg 4T #2.