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Toxins Oct 2020Sialorrhea, or excessive saliva beyond the margin of the lip, is a common problem in many neurological diseases. Previously, sialorrhea has been underrecognized in... (Review)
Review
Sialorrhea, or excessive saliva beyond the margin of the lip, is a common problem in many neurological diseases. Previously, sialorrhea has been underrecognized in Parkinson's disease (PD) patients. Despite this, many patients rank sialorrhea as one of the most debilitating complaints of Parkinson's disease. Previous treatment for sialorrhea has been suboptimal and has been plagued by significant side effects that are bothersome and can be dangerous in patients with a concurrent neurodegenerative disease. This review sought to review the anatomy, function, and etiology of sialorrhea in PD. It then sought to examine the evidence for the different treatments of sialorrhea in PD, and further examined newer evidence for safety and efficacy in minimally invasive treatment such as botulinum toxin.
Topics: Acetylcholine Release Inhibitors; Animals; Botulinum Toxins, Type A; Humans; Parkinson Disease; Salivary Glands; Salivation; Sialorrhea; Treatment Outcome
PubMed: 33142833
DOI: 10.3390/toxins12110691 -
Drugs of Today (Barcelona, Spain : 1998) Jun 2005Only a few drugs can induce drooling (sialorrhea or hypersalivation) to a clinically significant degree. When significant drooling occurs, however, it can pose a vexing... (Review)
Review
Only a few drugs can induce drooling (sialorrhea or hypersalivation) to a clinically significant degree. When significant drooling occurs, however, it can pose a vexing management problem. Drooling is either caused by an increase in saliva flow that cannot be compensated for by swallowing, or by impaired swallowing that cannot handle normal or even reduced amounts of saliva. Major medication groups that are clearly associated with drooling are antipsychotics, particularly clozapine, and direct and indirect cholinergic agonists that are used to treat dementia of the Alzheimer type and myasthenia gravis. Drooling is also caused by certain heavy metal toxins (mercury and thallium); from exposure to irreversible acetylcholinesterase inhibitors (insecticides and nerve agents); and by a handful of other drugs (e.g., yohimbine, mucosa-irritating antibiotics). The treatment of medication-induced drooling is often only symptomatic and attempts to decrease saliva to amounts that can be swallowed (to prevent "pool and drool"). Most pharmacological approaches reduce cholinergic tone, either systemically (e.g., atropine-related oral anticholinergics) or more locally (e.g., sublingual ipratropium spray); or increase adrenergic tone (e.g., clonidine patch). Recently, botulinum injections into the parotid gland have been used successfully to treat refractory cases.
Topics: Drug-Related Side Effects and Adverse Reactions; Humans; Poisoning; Salivary Glands; Sialorrhea
PubMed: 16110348
DOI: 10.1358/dot.2005.41.6.893628 -
American Family Physician Jun 2004Sialorrhea (drooling or excessive salivation) is a common problem in neurologically impaired children (i.e., those with mental retardation or cerebral palsy) and in...
Sialorrhea (drooling or excessive salivation) is a common problem in neurologically impaired children (i.e., those with mental retardation or cerebral palsy) and in adults who have Parkinson's disease or have had a stroke. It is most commonly caused by poor oral and facial muscle control. Contributing factors may include hypersecretion of saliva, dental malocclusion, postural problems, and an inability to recognize salivary spill. Sialorrhea causes a range of physical and psychosocial complications, including perioral chapping, dehydration, odor, and social stigmatization, that can be devastating for patients and their families. Treatment of sialorrhea is best managed by a clinical team that includes primary health care providers, speech pathologists, occupational therapists, dentists, orthodontists, neurologists, and otolaryngologists. Treatment options range from conservative (i.e., observation, postural changes, biofeedback) to more aggressive measures such as medication, radiation, and surgical therapy. Anticholinergic medications, such as glycopyrrolate and scopolamine, are effective in reducing drooling, but their use may be limited by side effects. The injection of botulinum toxin type A into the parotid and submandibular glands is safe and effective in controlling drooling, but the effects fade in several months, and repeat injections are necessary. Surgical intervention, including salivary gland excision, salivary duct ligation, and duct rerouting, provides the most effective and permanent treatment of significant sialorrhea and can greatly improve the quality of life of patients and their families or caregivers.
Topics: Humans; Patient Care Team; Quality of Life; Sialorrhea
PubMed: 15202698
DOI: No ID Found -
Developmental Medicine and Child... Aug 1980This study reports the long-term follow-up of a group of severely retarded cerebral-palsied children who were conditioned to control their oral drooling by means of an...
This study reports the long-term follow-up of a group of severely retarded cerebral-palsied children who were conditioned to control their oral drooling by means of an electronic device and shaping and conditioning procedures. Improvement was maintained in these children at nine months, and a larger group of children who were trained by the same method attained significant improvement in drooling both at one week and at three months.
Topics: Adolescent; Behavior Therapy; Deglutition; Education of Intellectually Disabled; Female; Humans; Male; Sialorrhea
PubMed: 7409336
DOI: 10.1111/j.1469-8749.1980.tb04349.x -
Archives of Physical Medicine and... Dec 1982Drooling can lead to physical and psychologic problems for the 10-13% of all persons with cerebral palsy who exhibit this symptom. Different therapeutic attempts have...
Drooling can lead to physical and psychologic problems for the 10-13% of all persons with cerebral palsy who exhibit this symptom. Different therapeutic attempts have been made to eliminate drooling, ranging from speech therapy to radical surgery. However, the effectiveness of all previous approaches is open to question since no satisfactory drool quantification technique has been devised. This paper describes a new inexpensive drool quantification system that has been tested with a number of cerebral palsy subjects. The system provides measures of drooled saliva to within 0.2ml, and allows for the possibility of more objective studies related to natural variations in drooling (for example, diurnal rhythms or activity levels) and clinical outcome studies of therapeutic interventions.
Topics: Adolescent; Cerebral Palsy; Child; Child, Preschool; Humans; Sialorrhea
PubMed: 7149944
DOI: No ID Found -
Monographs in Oral Science 2014The uncontrolled and continuous release of saliva from the mouth is known as drooling. While accepted as normal in young children up to 2 years of age, drooling in older... (Review)
Review
The uncontrolled and continuous release of saliva from the mouth is known as drooling. While accepted as normal in young children up to 2 years of age, drooling in older children and adolescents is secondary to altered orofacial neuromuscular control during development, and in the elderly it is a consequence of neurodegenerative disease. The underlying cause is patient inability to seal the lips, excess salivation and the inability to adequately swallow saliva. The estimated mean prevalence of drooling in such elderly patients is 37%. Drooling can give rise to irritation and excoriation of the skin around the mouth or chin, favors infections and gives rise to speech or eating disorders. Observational methods based on collection of the leaked saliva or documentation of the affected skin zones can be used to measure drooling. The management of such patients requires a multidisciplinary approach and comprises myofunctional therapy, behavioral change techniques, the administration of antisialagogues, botulinum toxin, or the use of certain surgical techniques designed to reduce salivary secretion or to deviate it towards posterior areas of the oral cavity.
Topics: Age Factors; Combined Modality Therapy; Deglutition; Facial Dermatoses; Humans; Patient Care Planning; Salivation; Sialorrhea
PubMed: 24862600
DOI: 10.1159/000358793 -
The Cochrane Database of Systematic... May 2022Motor neuron disease (MND), also known as amyotrophic lateral sclerosis (ALS), is a progressive neurodegenerative condition that may cause dysphagia, as well as limb... (Review)
Review
BACKGROUND
Motor neuron disease (MND), also known as amyotrophic lateral sclerosis (ALS), is a progressive neurodegenerative condition that may cause dysphagia, as well as limb weakness, dysarthria, emotional lability, and respiratory failure. Since normal salivary production is 0.5 L to 1.5 L daily, loss of salivary clearance due to dysphagia leads to salivary pooling and sialorrhea, often resulting in distress and inconvenience to people with MND. This is an update of a review first published in 2011.
OBJECTIVES
To assess the effects of treatments for sialorrhea in MND, including medications, radiotherapy and surgery.
SEARCH METHODS
On 27 August 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov and the WHO ICTRP. We checked the bibliographies of the identified randomized trials and contacted trial authors as needed. We contacted known experts in the field to identify further published and unpublished papers.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) and quasi-RCTs, including cross-over trials, on any intervention for sialorrhea and related symptoms, compared with each other, placebo or no intervention, in people with ALS/MND.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane.
MAIN RESULTS
We identified four RCTs involving 110 participants with MND who were described as having intractable sialorrhea or bulbar dysfunction. A well-designed study of botulinum toxin B compared to placebo injected into the parotid and submandibular glands of 20 participants showed that botulinum toxin B may produce participant-reported improvement in sialorrhea, but the confidence interval (CI) was also consistent with no effect. Six of nine participants in the botulinum group and two of nine participants in the placebo group reported improvement (risk ratio (RR) 3.00, 95% CI 0.81 to 11.08; 1 RCT; 18 participants; low-certainty evidence). An objective measure indicated that botulinum toxin B probably reduced saliva production (in mL/5 min) at eight weeks compared to placebo (MD -0.50, 95% CI -1.07 to 0.07; 18 participants, moderate-certainty evidence). Botulinum toxin B may have little to no effect on quality of life, measured on the Schedule for Evaluation of Individual Quality of Life direct weighting scale (SEIQoL-DW; 0-100, higher values indicate better quality of life) (MD -2.50, 95% CI -17.34 to 12.34; 1 RCT; 17 participants; low-certainty evidence). The rate of adverse events may be similar with botulinum toxin B and placebo (20 participants; low-certainty evidence). Trialists did not consider any serious events to be related to treatment. A randomized pilot study of botulinum toxin A or radiotherapy in 20 participants, which was at high risk of bias, provided very low-certainty evidence on the primary outcome of the Drool Rating Scale (DRS; range 8 to 39 points, higher scores indicate worse drooling) at 12 weeks (effect size -4.8, 95% CI -10.59 to 0.92; P = 0.09; 1 RCT; 16 participants). Quality of life was not measured. Evidence for adverse events, measured immediately after treatment (RR 7.00, 95% CI 1.04 to 46.95; 20 participants), and after four weeks (when two people in each group had viscous saliva) was also very uncertain. A phase 2, randomized, placebo-controlled cross-over study of 20 mg dextromethorphan hydrobromide and 10 mg quinidine sulfate (DMQ) found that DMQ may produce a participant-reported improvement in sialorrhea, indicated by a slight improvement (decrease) in mean scores for the primary outcome, the Center for Neurologic Study Bulbar Function Scale (CNS-BFS). Mean total CNS-BFS (range 21 (no symptoms) to 112 (maximum symptoms)) was 53.45 (standard error (SE) 1.07) for the DMQ treatment period and 59.31 (SE 1.10) for the placebo period (mean difference) MD -5.85, 95% CI -8.77 to -2.93) with a slight decrease in the CNS-BFS sialorrhea subscale score (range 7 (no symptoms) to 35 (maximum symptoms)) compared to placebo (MD -1.52, 95% CI -2.52 to -0.52) (1 RCT; 60 participants; moderate-certainty evidence). The trial did not report an objective measure of saliva production or measure quality of life. The study was at an unclear risk of bias. Adverse events were similar to other trials of DMQ, and may occur at a similar rate as placebo (moderate-certainty evidence, 60 participants), with the most common side effects being constipation, diarrhea, nausea, and dizziness. Nausea and diarrhea on DMQ treatment resulted in one withdrawal. A randomized, double-blind, placebo-controlled cross-over study of scopolamine (hyoscine), administered using a skin patch, involved 10 randomized participants, of whom eight provided efficacy data. The participants were unrepresentative of clinic cohorts under routine clinical care as they had feeding tubes and tracheostomy ventilation, and the study was at high risk of bias. The trial provided very low-certainty evidence on sialorrhea in the short term (7 days' treatment, measured on the Amyotrophic Lateral Scelerosis Functional Rating Scale-Revised (ALSFRS-R) saliva item (P = 0.572)), and the amount of saliva production in the short term, as indicated by the weight of a cotton roll (P = 0.674), or daily oral suction volume (P = 0.69). Quality of life was not measured. Adverse events evidence was also very uncertain. One person treated with scopolamine had a dry mouth and one died of aspiration pneumonia considered unrelated to treatment.
AUTHORS' CONCLUSIONS
There is some low-certainty or moderate-certainty evidence for the use of botulinum toxin B injections to salivary glands and moderate-certainty evidence for the use of oral dextromethorphan with quinidine (DMQ) for the treatment of sialorrhea in MND. Evidence on radiotherapy versus botulinum toxin A injections, and scopolamine patches is too uncertain for any conclusions to be drawn. Further research is required on treatments for sialorrhea. Data are needed on the problem of sialorrhea in MND and its measurement, both by participant self-report measures and objective tests. These will allow the development of better RCTs.
Topics: Amyotrophic Lateral Sclerosis; Botulinum Toxins, Type A; Clinical Trials, Phase II as Topic; Deglutition Disorders; Diarrhea; Humans; Motor Neuron Disease; Nausea; Randomized Controlled Trials as Topic; Saliva; Scopolamine Derivatives; Sialorrhea
PubMed: 35593746
DOI: 10.1002/14651858.CD006981.pub3 -
CMAJ : Canadian Medical Association... May 2024
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Journal of the American Dental... Jan 1996
Topics: Cholinergic Antagonists; Glycopyrrolate; Hernia, Diaphragmatic; Humans; Middle Aged; Sialorrhea
PubMed: 8568093
DOI: 10.14219/jada.archive.1996.0010 -
Journal of Oral Pathology & Medicine :... Apr 2009Drooling is the overflowing of saliva from the mouth. It is mainly due to neurological disturbance and less frequently to hypersalivation. Drooling can lead to... (Review)
Review
INTRODUCTION
Drooling is the overflowing of saliva from the mouth. It is mainly due to neurological disturbance and less frequently to hypersalivation. Drooling can lead to functional and clinical consequences for patients, families, and caregivers. The aim of this review is to emphasize the clinical aspects of the assessing and management of drooling.
METHODS
All papers and clinical reviews of drooling in the electronic data bases (Medline, PubMed, Embase and the Cochrane Library) for the past 40 years in any languages have been evaluated.
RESULTS
The severity of drooling and the effects on the quality of life of the patient and family, help to establish a prognosis and to decide the therapeutic regimen. Treatment options range from conservative therapy to medication, radiation, or surgery, and often a combination is needed.
CONCLUSIONS
Chronic drooling remains a problem that can be difficult to manage. Despite the acceptable results obtained with most of the treatments, none is free of undesirable effects.
Topics: Humans; Muscarinic Antagonists; Nervous System Diseases; Neuromuscular Agents; Physical Therapy Modalities; Salivary Glands; Sialorrhea
PubMed: 19236564
DOI: 10.1111/j.1600-0714.2008.00727.x