Pharmacotherapy for reducing saliva and droplet production in airborne procedures may help to decrease the COVID-19 transmission: A hypothesis.

The pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected health care service practices worldwide. Therefore, a global reaction to prepare health care systems is mandatory. Preventing the transmission of this virus during medical and dental procedures producing airborne particles and droplets, could be considered as one of the main venues in prevention of Coronavirus disease 2019 (COVID-19) transmission in health care facilities. To the best of our knowledge, no intervention has been approved for this purpose, so the major suggestion in this regard is using personal preventive equipment (PPE) and similar measures as well as other sanitizing practices. Since we do not know how long we should face this universal issue, using antecedent pharmacotherapies for reducing oral-respiratory secretions to combat this virus might play a role in this regard. Given that currently there is no definitive cure for COVID-19, so we hypothesize that, considering drug solutions to reduce saliva and droplet production may be helpful in controlling Coronavirus spread during aerosol and respiratory droplet producing procedures.

Can muscle vibration be the future in the treatment of cerebral palsy-related drooling? A feasibility study.

Background: Drooling is an involuntary loss of saliva from the mouth, and it is a common problem for children with cerebral palsy (CP). The treatment may be pharmacological, surgical, or speech-related. Repeated Muscle Vibration (rMV) is a proprioceptive impulse that activates fibers Ia reaching the somatosensory and motor cortex. Aim: The aim of the study is to evaluate the effectiveness of rMV in the treatment of drooling in CP. Design, setting and population: This was a rater blinded prospective feasibility study, performed at the "Gli Angeli di Padre Pio" Foundation, Rehabilitation Centers (Foggia, Italy), involving twenty-two CP patients affected by drooling (aged 5-15, mean 9,28 ± 3,62). Children were evaluated at baseline (T0), 10 days (T1), 1 month (T2) and 3 months (T3) after the treatment. Methods: The degree and impact of drooling was assessed by using the Drooling Impact Scale (DIS), the Drooling Frequency and Severity Scale (DFSS), Visual Analogue Scale (VAS) and Drooling Quotient (DQ). An rMV stimulus under the chin symphysis was applied with a 30 min protocol for 3 consecutive days. Results: The statistical analysis shows that DIS, DFSS, VAS, DQ improved with significant differences in the multiple comparisons between T1 vs T2, T1 vs T3 and T1 vs T4 (p≤0.001). Conclusion This study demonstrates that rMV might be a safe and effective tool in reducing drooling in patients with CP. The vibrations can improve the swallowing mechanisms and favor the acquisition of the maturity of the oral motor control in children with CP.

Efectos del kinesiotaping en el control de la sialorrea en niños con patologías del sistema nervioso central: revisión sistemática / Effects of kinesiotaping on the control of sialorrhoea in children with central nervous system conditions: a systematic review

Introducción: La sialorrea es un signo importante en los niños con patologías del sistema nervioso central que afecta gravemente a la salud y a la calidad de vida. El kinesiotaping se presenta como una alternativa no invasiva útil para el control de la deglución de la saliva. Objetivo: Examinar la eficacia del kinesiotaping como recurso terapéutico en el control de la sialorrea. Pacientes y métodos: Se realizo una búsqueda bibliográfica en las bases de datos Scopus, PubMed, Web of Science, Cochrane Library, Science Direct y Google Académico, usando los términos «bandages», «tape», «kinesiotaping», «sialorrea», «deglutition», «drooling» y «swallowing difficulty», y se valoró la calidad metodológica con la Critical Review Form-Quantitative Studies y la escala de Oxford. Resultados: Se seleccionaron diez estudios para la revisión: seis aplicaron kinesiotaping en la zona suprahioidea y cuatro en la zona del músculo orbicular de los labios. Todos los estudios muestran diferencias significativas con el uso de las diferentes técnicas de tratamiento, sin establecer diferencias significativas entre otras técnicas y el kinesiotaping. Conclusiones: Los estudios de alta calidad metodológica son escasos; sin embargo, se describen mejoras significativas en los resultados y sin efectos adversos, lo que puede influir positivamente en la clínica y en la terapia cotidiana

Introduction: Sialorrhoea is an important sign in children with central nervous system conditions that seriously affects health and quality of life. Kinesiotaping is presented as a non-invasive alternative that is useful in controlling the swallowing of saliva. Aim: To examine the efficacy of kinesiotaping as a therapeutic resource in the control of sialorrhoea. Patients and methods: A bibliographic search was carried out in the databases Scopus, PubMed, Web of Science, Cochrane library, Science Direct and Google Scholar, using the terms 'bandages', 'tape', 'kinesiotaping', 'sialorrea', 'deglutition', 'drooling' and 'swallowing difficulty', and the methodological quality was evaluated with Form-Quantitative Studies and the Oxford scale. Results: Ten studies were selected for review: six of which applied kinesiotaping in the suprahyoid area and four in the area of the orbicularis muscle of the lips. All studies show significant differences in the use of different treatment techniques, but without any significant differences between kinesiotaping and other techniques. Conclusions: Studies of high methodological quality are scarce; however, significant improvements in outcomes and no adverse effects are reported, which may have a positive influence on the clinical features and on day-to-day therapy

Addition of Kinesio Taping of the orbicularis oris muscles to speech therapy rapidly improves drooling in children with neurological disorders.

OBJECTIVE: To evaluate the effects of Kinesio Taping (KT) of the orbicularis oris muscles as an adjunct to standard therapy for drooling. METHODS: Fifteen children with neurological disorders and drooling received speech therapy and twice-weekly KT of the orbicularis muscles over a 30-day period. Drooling was assessed by six parameters: impact on the life of the child and caregiver; severity of drooling; frequency of drooling; drooling volume (estimated by number of bibs used); salivary leak; and interlabial gap. Seven markers of oral motor skills were also assessed. RESULTS: KT of the orbicularis oris region reduced the interlabial gap. All oral motor skills and almost all markers of drooling improved after 15 days of treatment. CONCLUSION: In this sample of children with neurological disorders, adding KT of the orbicularis oris muscles to speech therapy caused rapid improvement in oral motor skills and drooling.

Glycopyrrolate in comparison to hyoscine hydrobromide and placebo in the treatment of hypersalivation induced by clozapine (GOTHIC1): study protocol for a randomised controlled feasibility study.

BACKGROUND: Clozapine is the only medication licensed for the treatment of resistant schizophrenia in the UK. Although efficacious, a common and unpopular side effect of clozapine treatment is clozapine-induced hypersalivation (CIH), which can contribute to non-adherence. The standard treatment for CIH in the UK is hyoscine hydrobromide but this may aggravate cognitive deficits in patients with schizophrenia while glycopyrrolate may be an effective alternative with a more tolerable side effect profile. There is currently no convincing evidence for hyoscine, or any other medication, as an effective treatment for CIH. METHODS/DESIGN: This is a multicentre randomised, double-blind, placebo-controlled feasibility study of glycopyrronium bromide (glycopyrrolate) and hyoscine hydrobromide (hyoscine) in patients with clozapine-induced hypersalivation. We aim to recruit 42 patients who have been prescribed clozapine and are experiencing hypersalivation, and randomise them to one of three study arms (either hyoscine, glycopyrrolate or placebo). The primary outcome measures will be the participant recruitment and attrition rates, and the secondary outcome will be the metrics of the daytime hypersalivation measure. After a 1-week washout period (discontinuing CIH medication, if any), there will be a 4-week treatment period where participants will be titrated up to the maximum tolerated dose of hyoscine, glycopyrrolate or placebo. Measurements of daytime salivation, nocturnal salivation, cognition and side effects will be taken during home visits in week 2 and week 5. Information on salivation and side effects will also be taken through telephone calls in week 3 and week 4. To gather information on the experience of study participants, exit interviews will also be requested with all participants who drop out of the study and a sample of participants who complete the study. DISCUSSION: There is currently no convincing evidence for hyoscine, or any other medication, as an effective treatment for CIH. There is promising evidence that glycopyrrolate may be more successful in the treatment of CIH causing fewer cognitive side effects. We propose to conduct a randomised placebo-controlled feasibility study of glycopyrrolate and hyoscine in the treatment of clozapine-induced hypersalivation to inform the design of a future efficacy trial. TRIAL REGISTRATION: Clinicaltrials.gov NCT02613494 , 23 November 2015.

Interim prosthesis preventing tongue protrusion following mandibular alveolar ridge and lower lip resection in a surgically compromised patient.

Carcinomas of the mandibular buccogingival region being aggressive rapidly destroy the supporting bone and adjacent soft tissues, making it mandatory for the oncosurgeon to resect substantial amounts of involved hard and soft tissues. Segmental mandibulectomy -followed by immediate bony and soft tissue reconstruction is the most acceptable approach. However, immediate reconstruction may not always be feasible or possible due to high recurrences potential of lesion, inaccessible residual pathology, or systemic -conditions that pose a risk for graft inosculation. In certain cases, where large portion of lower lip also needs to be sacrificed with alveolar resection, protrusion of tongue through the defect beyond the lip confines leads to drooling of saliva, difficulty in speech and worsening of esthetic appearance, social isolation, and compromised quality of life. So, pending reconstruction and definitive rehabilitation, patients would require provisional treatment to control some of the ill effects. This article presents a simple technique for fabrication of a provisional prosthesis for preventing tongue protrusion, salivary drooling following mandibular alveolar ridge and lip resection.

Onabotulinumtoxin A Treatment of Drooling in Children with Cerebral Palsy: A Prospective, Longitudinal Open-Label Study.

The aim of this prospective open-label study was to treat disabling drooling in children with cerebral palsy (CP) with onabotulinumtoxin A (A/Ona, Botox®) into submandibular and parotid glands and find the lowest effective dosage and least invasive method. A/Ona was injected in 14 children, Mean age 9 years, SD 3 years, under ultrasonic guidance in six successive Series, with at least six months between injections. Doses and gland involvement increased from Series A to F (units (U) per submandibular/parotid gland: A, 10/0; B, 15/0; C, 20/0; D, 20/20; E, 30/20; and F, 30/30). The effect was assessed 2, 4, 8, 12, and 20 weeks after A/Ona (drooling problems (VAS), impact (0-7), treatment effect (0-5), unstimulated whole saliva (UWS) flow and composition)) and analyzed by two-way ANOVA. The effect was unchanged-moderate in A to moderate-marked in F. Changes in all parameters were significant in E and F, but with swallowing problems ≤5 weeks in 3 of 28 treatments. F had largest VAS and UWS reduction (64% and 49%). We recommend: Start with dose D A/Ona (both submandibular and parotid glands and a total of 80 U) and increase to E and eventually F (total 120 U) without sufficient response.

[Orthodontic silicone positioner for the treatment of oral symptoms in Amyotrophic Lateral Sclerosis (ALS) patients].

ALS is considered a neurodegenerative disorder caused by progressive death of specific neuronal populations within the gray matter of the central nervous system. The cause of cell death is unknown and patients with ALS will live 3 to 5 years from disease onset. A common cause of death is neuromuscular respiratory failure or cardiac arrhythmias due to insufficient oxygen. The patients develop multiple symptoms and the focus of management is to maintain their quality of life. Orofacial manifestations in ALS are secondary to motor deficits, resulting in dysphagia, muscle spasticity, rigidity and tremor of the orofacial musculature, which can induce soft tissue trauma and sialorrhea. In this report the management of ALS oral symptoms, by means of an elastic silicone full coverage occlusal splint, often used as an orthodontic positioner, is discussed, as well as its advantages and alternatives. The positioner was easily tolerated by the patients who reported improvement in soft tissue trauma lesions due to accidental self biting, and improved control of the drooling due to excessive saliva and difficulty in swallowing.

Emerging drugs for autonomic dysfunction in Parkinson's disease.

INTRODUCTION: Autonomic dysfunction, including orthostatic hypotension (OH), sialorrhea, sexual dysfunction, urinary dysfunction and constipation is a common feature of Parkinson's disease (PD). Even though its treatment has been recognized as a major unmet need in PD, there is a paucity of clinical trials to assess their treatment. AREAS COVERED: Evidence about the efficacy and safety of available treatments for autonomic dysfunction is summarized. Potential targets for upcoming therapies are then discussed in light of what is currently known about the physiopathology of each disorder in PD. Proof-of-concept trials and circumstantial evidence about treatments for autonomic dysfunction as well as upcoming clinical trials are discussed. Finally, critical aspects of clinical trials design are considered. EXPERT OPINION: Botulinum toxin (BTX) or glycopyrrolate might be used for sialorrhea whereas macrogol could be useful in constipation. There is preliminary evidence suggesting that fludrocortisone, domperidone, droxidopa or fipamezole may be effective for the treatment of OH. Tropicamide, clonidine or radiotherapy are under development for sialorrhea. Sildenafil may be effective for the treatment of erectile dysfunction; BTX or behavioral therapy for urinary incontinence and lubiprostone and probiotics for constipation. Sound clinical trials are needed in order to allow firm evidence-based recommendations about these treatments.

Botulinum toxin A for oral cavity cancer patients: in microsurgical patients BTX injections in major salivary glands temporarily reduce salivary production and the risk of local complications related to saliva stagnation.

In patients suffering from oral cavity cancer surgical treatment is complex because it is necessary to remove carcinoma and lymph node metastasis (through a radical unilateral or bilateral neck dissection) and to reconstruct the affected area by means of free flaps. The saliva stagnation in the post-operative period is a risk factor with regard to local complications. Minor complications related to saliva stagnation (such as tissue maceration and wound dehiscence) could become major complications compromising the surgery or the reconstructive outcome. In fact the formation of oro-cutaneous fistula may cause infection, failure of the free flap, or the patient’s death with carotid blow-out syndrome. Botulinum injections in the major salivary glands, four days before surgery, temporarily reduces salivation during the healing stage and thus could reduce the incidence of saliva-related complications. Forty three patients with oral cancer were treated with botulinum toxin A. The saliva quantitative measurement and the sialoscintigraphy were performed before and after infiltrations of botulinum toxin in the major salivary glands. In all cases there was a considerable, but temporary, reduction of salivary secretion. A lower rate of local complications was observed in the post-operative period. The salivary production returned to normal within two months, with minimal side effects and discomfort for the patients. The temporary inhibition of salivary secretion in the post-operative period could enable a reduction in saliva-related local complications, in the incidence of oro-cutaneous fistulas, and improve the outcome of the surgery as well as the quality of residual life in these patients.

Clinical effects of adjunctive atropine during ketamine sedation in pediatric emergency patients.

INTRODUCTION: The prophylactic coadministration of anticholinergics during dissociative sedation has been considered necessary to mitigate ketamine-associated hypersalivation. Given recent conflicting conclusions regarding adjunctive atropine, we compared the incidence of hypersalivation, degree of secretion, and related side effects with atropine or placebo as an adjunct to intravenous (IV) ketamine sedation for children. METHODS: This controlled trial randomized children, 1 to 10 years old, requiring ketamine sedation in a tertiary emergency department to receive 0.01 mg/kg of atropine or placebo, along with IV ketamine (2 mg/kg). A nurse rated preprocedure and postprocedure salivation on a 100-mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation. RESULTS: During 27 months, 140 patients were enrolled. Baseline characteristics did not differ between the 2 groups (P > .05). Secretion was significantly less in the atropine vs placebo group (mean visual analog scale score ± SD, 21.2 ± 13.1 [preprocedure] to 16.5 ± 9.9 [postprocedure] vs 22.4 ± 13.5 [preprocedure] to 27.0 ± 15.9 [postprocedure], respectively; P < .05). Visual analog scale scores greater than 50 were assigned to 7 (9.7%) of 72 and 1 (1.5%) of 68 patients in the placebo and atropine groups, respectively; these patients needed only medical procedures such as suction or airway repositioning. Heart rate was significantly higher in the atropine group compared with the placebo group (P < .05). There were no significant differences between the groups in terms of other adverse events. CONCLUSION: Atropine as an adjunct to IV ketamine sedation in children significantly reduced hypersalivation, without providing a clinical benefit.

Psychosocial, feeding, and drooling outcomes in children with Beckwith Wiedemann syndrome following tongue reduction surgery.

OBJECTIVE: Macroglossia is a common feature of Beckwith Wiedemann Syndrome (BWS). Tongue reduction surgery (TRS) is advocated to overcome, or reduce, the secondary effects of macroglossia. Macroglossia may affect a child's cosmetic appearance, feeding, and drooling function. However, no study has systematically reported on feeding, drooling, or psychosocial outcomes preoperatively and postoperatively in this group. This study aimed to describe the presurgical and postsurgical psychosocial, feeding, and drooling outcomes of children with macroglossia associated with BWS and to determine the effect of TRS on these areas. DESIGN: Clinical cohort study. PARTICIPANTS: Ten consecutively admitted children with BWS (age at surgery from 9 months to 4 years, 9 months [4;9]; mean, 2;7) were assessed preoperatively, 3 months postoperatively, and at long-term follow-up. MAIN OUTCOME MEASURES: A parental report questionnaire, the Brodsky drooling scale, and a feeding rating scale. RESULTS: Parents reported that macroglossia had a negative impact cosmetically that was ameliorated following surgery. Macroglossia caused a range of feeding difficulties presurgically by preventing lip seal and bolus manipulation during the oral preparatory phase. Excessive drooling was present in all cases presurgically. This resolved partially across the group postsurgically, with almost complete recovery at longer-term follow-up assessment. CONCLUSIONS: Presurgically, children show a common profile of feeding and drooling impairment with negative effects on cosmetic appearance. Our preliminary results demonstrate that TRS has a positive impact on these features with good outcomes for children with BWS.

Promoting mouth-drying responses to reduce drooling effects by persons with intellectual and multiple disabilities: a study of two cases.

This study assessed the use of microswitch technology to promote mouth-drying responses and thereby reduce the effects of drooling by two adults with severe intellectual and multiple disabilities. Mouth-drying responses were performed via a special napkin that contained pressure sensors, a microprocessor and an MP3 to monitor the responses and ensure positive stimulation contingent on them. Initially, the responses produced 10 or 15 s of preferred stimulation. Subsequently, preferred stimulation was supplemented with matching periods of lower-grade stimulation to extend the inter-response intervals. Results showed that both participants (a) learned to dry their mouth consistently and reduce their chin wetness during the intervention, (b) stabilized their responding at lower frequencies as the lower-grade stimulation was added to the preferred stimulation, and (c) maintained the latter levels at a 3-month follow-up. Procedure and response conditions and outcome implications are discussed.

The management of drooling in motor neurone disease.

Drooling is a common and potentially distressing symptom in those with motor neurone disease. A coordinated multidisciplinary approach is required to optimally manage this symptom. Both pharmacological and non-pharmacological strategies are required, and when drugs are used, off-label prescribing in terms of indication or route of administration is common. Further research needs to explore ways of enhancing swallowing ability as well as ways of optimizing drug therapies.

The effect of lip strengthening exercises in children and adolescents with myotonic dystrophy type 1.

OBJECTIVE: Myotonic dystrophy type 1 (DM1) is a slowly progressive neuromuscular disease. Most children and adolescents with DM1 have weak lips and impaired lip function. The primary aim of the present study was to investigate if regular training with an oral screen could strengthen the lip muscles in children and adolescents with DM1. If lip strength improved, a secondary aim would be to see if this could have an immediate effect on lip functions such as lip mobility, eating and drinking ability, saliva control, and lip articulation. METHODS: Eight school aged children and adolescents (7-19 years) with DM1 were enrolled in an intervention study with a single group counterbalanced design. After three baseline measurements four children (Subgroup A) were randomly chosen to start 16 weeks therapy while the others (Subgroup B) acted as controls without therapy. After 16 weeks the subgroups changed roles. During treatment the participants exercised lip strength with an oral screen for 16 min, 5 days/week. Lip force, grip force (control variable), and lip articulation were followed-up every fourth week. At baseline, after treatment, and after maintenance, the assessment protocol was completed with measurements of lip mobility using 3D motion analysis and parental reports concerning eating ability and saliva control. RESULTS: Seven of eight participants improved maximal lip strength and endurance but only four showed significant change. Increased lip strength did not automatically lead to improved function. There was a wide intra-individual variation concerning speech and eating ability within and between assessments. The treatment programme could be carried out without major problems but the frequency and the effect of training were affected by recurrent infections in some. CONCLUSIONS: Maximal lip force and lip force endurance can improve in school aged children and adolescents with DM1. Improved lip strength alone cannot be expected to have an effect on lip articulation, saliva control, or eating and drinking ability in this population. Lip strengthening exercises can be a complement but not a replacement for speech therapy and dysphagia treatment. A prefabricated oral screen is an easy to use tool suitable for strengthening lip exercises.

Recontouring commissuroplasty after reconstruction of large defects after resections for head and neck cancer with commissure involvement using an anterolateral thigh flap.

The aim of this study was to describe our technique for recontouring commissuroplasty after reconstruction of large, through-and-through perioral defects in patients with head and neck cancer with emphasis on functional and cosmetic outcome. This technique was used in 15 patients aged between 33 and 66 years. Recontouring required liposuction, arrow-headed advancement flap, and anchoring vector sutures. All patients had satisfactory functional and cosmetic results and healed without complication. Function was evaluated to find out whether the patient was free of drooling and able to accommodate more food postoperatively. Aesthetic evaluation was subjective, and the patients themselves decided using a visual analogue cosmesis scale. Our combined procedures provide a predictable way of creating a new oral commissure, improving postoperative drooling, and increasing the intraoral space after reconstruction.

Drooling of saliva in children with cerebral palsy-etiology, prevalence, and relationship to salivary flow rate in an Indian population.

The prevalence of drooling, the impact of various etiological factors on its severity, and its relationship to salivary flow rate were assessed in 113 individuals with cerebral palsy (CP). In this study, there were 74 males and 39 females with an age range of 6-18 years who were attending a special school in Chennai, India. The severity of drooling was assessed by visual examination; demographics and data regarding severity and control of drooling were collected via a questionnaire. Data regarding the type of CP and drugs taken by the children were obtained from the medical records maintained by the school. The unstimulated salivary flow rate of these children was determined through a passive method. The overall incidence of drooling was 48.7%, with 17.7% having severe drooling. Individuals with athetosis had the least severe amount of drooling. There was a significant relationship between ability to close the mouth and the severity of drooling. The severity of drooling was reduced with age. There was no significant difference in the mean salivary flow rate of those children who drooled and those who did not.

Botulinum toxin A injection of salivary glands in children with drooling and chronic aspiration.

PURPOSE: To review outcomes of ultrasound (US)-guided percutaneous submandibular gland injection of botulinum toxin A (BTX-A) in the treatment of drooling and chronic aspiration. MATERIALS AND METHODS: A 3-year retrospective review was performed of 220 US-guided salivary gland injections in 36 patients. There were 21 male patients and 15 female patients with an age range of 1.4 to 19.8 years (mean, 8.6 y) and a weight range of 7.8 to 73 kg (mean, 24.4 kg). The mean pretreatment analysis period was 48 months and the mean follow-up period was 21 months. The study group was divided into groups with anterior (n = 9) and posterior (n = 27) drooling, with those with both (n = 10) included in the posterior group. RESULTS: All procedures were technically successful. Bilateral submandibular injections were performed in 34 procedures and bilateral submandibular and parotid injections were performed in 38 procedures. Of the 27 patients with posterior drooling, improvement occurred in 24 patients (88%), no improvement was seen in two (8%), and one (4%) was lost to follow-up. Of the nine patients with anterior drooling, six (66%) showed improvement, there was no response in two (22%), and one (12%) was lost to follow-up. The total number of hospitalizations for respiratory issues and presumed aspiration pneumonia decreased by 56.4% per year in the patients with posterior drooling. There was one procedure-related complication: an episode of self-limited oral bleeding. CONCLUSION: Salivary gland BTX-A injection for salivary control shows promising results in decreasing saliva production and frequency of respiratory symptoms in children with drooling and chronic aspiration.

Use of botulinum toxin in dentistry.

A growing number of dentists are providing botulinum toxin to patients. The research presented here outlines potential uses of Botox related to oral health and facial problems as compared to traditional treatment methods. The administration of Botox (historically done by dermatologists and neurologists) may fall under dentists' jurisdiction, as their training and knowledge encompasses the entire head and neck. A review is made of the literature, based on Ovid and PubMed searches, selecting articles describing the injection of botulinum toxin A in areas related to the oral cavity and the face, excluding cosmetic purposes.