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Jost WH, Bäumer T, Bevot A, Birkmann U, Buhmann C, Grosheva M, Guntinas-Lichius O, Laskawi R, Paus S, Pflug C, Schroeder AS, Spittau B, Steffen A, Wilken B, Winterholler M, Berweck S. Botulinum neurotoxin type A in the interdisciplinary treatment of sialorrhea in adults and children-update and practice recommendations. Front Neurol 2023; 14:1275807. [PMID: 38162447 PMCID: PMC10757066 DOI: 10.3389/fneur.2023.1275807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/14/2023] [Indexed: 01/03/2024] Open
Abstract
Sialorrhea is defined as a chronic excessive flow of saliva from the mouth, often with adverse consequences for health and quality of life of patients. In addition to currently used non-drug treatment and systemic drugs, intraglandular Botulinum Neurotoxin A (BoNT/A) injections have been examined in case studies, controlled trials and clinical practice. Two pivotal Phase III trials recently led to market approval in the USA and EU for IncobotulinumtoxinA [Xeomin®, IncoBoNT/A, Clostridium botulinum neurotoxin type A (150 kD), free from complexing proteins, Merz Pharmaceuticals GmbH] for treatment of chronic sialorrhea in adults and pediatric patients. This review provides a multidisciplinary approach to discuss the current state of sialorrhea therapy as well as benefits and current limitations of BoNT/A injections. A consensus regarding treatment recommendations made available to physicians in Germany in 2022 has now been updated here for presentation to an international audience. This review provides a framework including a flow chart for patient selection, recommendations for dosing and the injection process, as well as a discussion of therapeutic goals, long-term benefits and safety aspects. This review is aimed at supporting physicians in developing multidisciplinary and individualized treatment approaches to achieve optimal benefits for patients.
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Affiliation(s)
| | - Tobias Bäumer
- Institute of Systemic Motor Science, CBBM, University of Lübeck, Lübeck, Germany
| | - Andrea Bevot
- Department of Neuropediatrics and Developmental Medicine, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Ulrich Birkmann
- Department of Neurology, Schluckambulanz, GFO Clinics Troisdorf, Troisdorf, Germany
| | - Carsten Buhmann
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Grosheva
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | | | - Rainer Laskawi
- Department of Otorhinolaryngology, University Hospital Göttingen, Göttingen, Germany
| | - Sebastian Paus
- Department of Neurology, GFO Clinics Troisdorf, Troisdorf, Germany
| | - Christina Pflug
- Department of Voice, Speech and Hearing Disorders, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - A. Sebastian Schroeder
- Clinic for Child Neurology and Social Pediatrics, Child Center Maulbronn, Maulbronn, Germany
| | - Björn Spittau
- Anatomy and Cell Biology, Medical School OWL, Bielefeld University, Bielefeld, Germany
| | - Armin Steffen
- Department for Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Bernd Wilken
- Department of Pediatric Neurology, Klinikum Kassel, Kassel, Germany
| | - Martin Winterholler
- Department of Neurology, Sana Hospital Rummelsberg, Nuremberg/Schwarzenbruck, Germany
| | - Steffen Berweck
- Specialist Center for Pediatric Neurology, Neurorehabilitation and Epileptology, Schön Clinic, Vogtareuth, Germany
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Jost WH, Bäumer T, Berweck S, Laskawi R, Spittau B, Steffen A, Winterholler M. [Therapy of Sialorrhea with Botulinum Toxin - An Update]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2022; 90:222-232. [PMID: 35453157 DOI: 10.1055/a-1802-3867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The most important salivary glands are the paired parotid and submandibular glands. Adults produce 1 to 1.5 liters of saliva which are then regularly swallowed. When the act of swallowing is disturbed, salivation occurs. More rarely, the cause can be found in increased saliva production, for example, when caused through medication. Sialorrhea impairs the quality of life substantially and is frequently often socially stigmatizing. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, as well as, in selected cases, radiation and surgical measures. Over the last 20 years, local injection of botulinum toxin has been successfully applied in the treatment of this condition. With approval of incobotulinumtoxinA toxin for children and adults, this procedure will become the therapy of choice for chronic sialorrhea. The results of the phase III registration trials have demonstrated high efficacy and good safety of the injection treatment in both children and adults.
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Affiliation(s)
| | - Tobias Bäumer
- Institut für Systemische Motorikforschung, CBBM, Sektion Zentrum für Seltene Erkrankungen, UKSH, Universität zu Lübeck, Lübeck, Germany
| | - Steffen Berweck
- Schön Klinik Vogtareuth, Vogtareuth, Germany.,Dr von Haunersches Kinderspital Kinderklinik und Kinderpoliklinik der Ludwig Maximilian Universitat München, München, Germany
| | - Rainer Laskawi
- Georg-August-Universitat Göttingen HNO-Klinik, Göttingen, Germany
| | - Björn Spittau
- Anatomie und Zellbiologie, Medizinische Fakultät OWL, Universität Bielefeld, Bielefeld, Germany
| | - Armin Steffen
- Universitätsklinikum Schleswig-Holstein Campus Lübeck HNO Klinik, Lübeck, Germany
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Jost WH, Bäumer T, Laskawi R, Slawek J, Spittau B, Steffen A, Winterholler M, Bavikatte G. Therapy of Sialorrhea with Botulinum Neurotoxin. Neurol Ther 2019; 8:273-288. [PMID: 31542879 PMCID: PMC6858891 DOI: 10.1007/s40120-019-00155-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Indexed: 12/11/2022] Open
Abstract
Botulinum neurotoxin (BoNT) is considered the treatment of choice for various symptoms and diseases such as focal dystonia and focal spasticity. The effects of BoNT on the salivary glands have also been known for years, but their use was limited because of a lack of approval studies. Now the indication of sialorrhea is approved in some countries for incobotulinumtoxinA, such as the USA and Europe, and therapy could also become the treatment of choice. According to the pivotal study, a dose of 100 units of incobotulinumtoxinA, which is divided into the parotid and submandibular glands, is recommended. RimabotulinumtoxinB is approved in the USA only. To define the value of this therapy, we must consider anatomy, physiology, and available therapies. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, and, in selected cases, radiotherapy and surgical procedures. A combination of different approaches is optional. On the basis of the evidence and clinical experience, BoNT injections will be the first line of pharmacotherapy for chronic sialorrhea.
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Affiliation(s)
| | - Tobias Bäumer
- Paediatric and Adult Movement Disorders and Neuropsychiatry, Institut of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Rainer Laskawi
- ENT Department, University Medical Center, Göttingen, Germany
| | - Jaroslaw Slawek
- Neurology Department, Medical University of Gdansk, Gdańsk, Poland
| | - Björn Spittau
- Center for Transdisciplinary Neurosciences Rostock (CTNR), University of Rostock, Rostock, Germany
| | - Armin Steffen
- Department for Otorhinolaryngology, University of Lübeck, UKSH, Lübeck, Germany
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Steffen A, Jost W, Bäumer T, Beutner D, Degenkolb-Weyers S, Groß M, Grosheva M, Hakim S, Kahl KG, Laskawi R, Lencer R, Löhler J, Meyners T, Rohrbach-Volland S, Schönweiler R, Schröder SC, Schröder S, Schröter-Morasch H, Schuster M, Steinlechner S, Urban R, Guntinas-Lichius O. Hypersalivation: update of the German S2k guideline (AWMF) in short form. J Neural Transm (Vienna) 2019; 126:853-862. [DOI: 10.1007/s00702-019-02000-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/27/2019] [Indexed: 12/11/2022]
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Restivo DA, Panebianco M, Casabona A, Lanza S, Marchese-Ragona R, Patti F, Masiero S, Biondi A, Quartarone A. Botulinum Toxin A for Sialorrhoea Associated with Neurological Disorders: Evaluation of the Relationship between Effect of Treatment and the Number of Glands Treated. Toxins (Basel) 2018; 10:toxins10020055. [PMID: 29382036 PMCID: PMC5848156 DOI: 10.3390/toxins10020055] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 01/22/2018] [Accepted: 01/22/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Sialorrhoea and drooling are disabling manifestations of different neurological disorders. The aim of this study was to evaluate the effects of botulinum neurotoxin type A (BoNT/A) injection on hypersalivation in 90 patients with neurological diseases of different aetiologies, and to define the minimum number of injected salivary glands to reduce sialorrhoea. Determining the minimum number of glands that need to be engaged in order to have a significant reduction in drooling may be very useful for establishing the minimum total dosage of BoNT/A that may be considered effective in the treatment of hypersalivation. Methods: Twenty-five mouse units (MU) of BoNT/A (onabotulinumtoxin A, Botox; Allergan, Irvine, CA, USA; 100 MU/2 mL, 0.9% saline; or incobotulinumtoxin A, Xeomin; Merz Pharma, Germany; 100 MU/2 mL, 0.9% saline) were percutaneously injected into the parotid (p) glands and/or submandibular (s) glands under ultrasound control. On this basis, patients were divided into three groups. In group A (30 patients), BoNT/A injections were performed into four glands; in group B (30 patients), into three glands, and in group C (30 patients), into two glands. Patients treated in three glands (group B) were divided into two subgroups based on the treated glands (2 p + 1 s = 15 patients; 2 s + 1 p = 15 patients). Similarly, patients being injected in two glands (group C) were subdivided into three groups (2 p = 10 patients; 1 p + 1 s = 10 patients; 2 s = 10 patients). In patients who were injected in three and two salivary glands, saline solution was injected into the remaining one and two glands, respectively. Assessments were performed at baseline and at 2 weeks after the injections. Results: BoNT/A significantly reduced sialorrhoea in 82 out of 90 patients. The effect was more evident in patients who had four glands injected than when three or two glands were injected. The injections into three glands were more effective than injections into two glands. Conclusions: Our results have shown that BoNT/A injections induced a significant reduction in sialorrhoea in most patients (91%). In addition, we demonstrated that sialorrhoea associated with different neurological diseases was better controlled when the number of treated glands was higher.
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Affiliation(s)
| | - Mariangela Panebianco
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool L271XF, UK.
| | - Antonino Casabona
- Department of Biomedical and Biotechnological Sciences, Section of Physiology, University of Catania, 95100 Catania, Italy.
| | - Sara Lanza
- UOC di Medicina Fisica e Riabilitazione, Comiso-Vittoria, ASP Ragusa, 97013 Ragusa, Italy.
| | | | - Francesco Patti
- DANA Department, "GF Ingrassia", Neuroscience Section-Multiple Sclerosis Center, University of Catania, 95100 Catania, Italy.
| | - Stefano Masiero
- School of Physical Medicine and Rehabilitation, University of Padua, 35121 Padua, Italy.
| | - Antonio Biondi
- Department of Surgery, University of Catania, 95100 Catania, Italy.
| | - Angelo Quartarone
- IRCCS Centro Neurolesi "Bonibo-Pulejo", via Provinciale Palermo, Contrada Casazza, 95124 Messina, Italy.
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Wu CC, Wuu YR, Jani A, Saraf A, Tai CH, Lapa ME, Andrew JIS, Tiwari A, Saadatmand HJ, Isaacson SR, Cheng SK, Wang TJC. Whole-brain Irradiation Field Design: A Comparison of Parotid Dose. Med Dosim 2017; 42:145-149. [PMID: 28479012 DOI: 10.1016/j.meddos.2017.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/27/2017] [Indexed: 10/19/2022]
Abstract
Whole-brain radiation therapy (WBRT) plays an important role in patients with diffusely metastatic intracranial disease. Whether the extent of the radiation field design to C1 or C2 affects parotid dose and risk for developing xerostomia is unknown. The goal of this study is to examine the parotid dose based off of the inferior extent of WBRT field to either C1 or C2. Patients treated with WBRT with either 30 Gy or 37.5 Gy from 2011 to 2014 at a single institution were examined. Parotid dose constraints were compared with Radiation Therapy Oncology Group (RTOG) 0615 nasopharyngeal carcinoma for a 33-fraction treatment: mean <26 Gy, volume constraint at 20 Gy (V20) < 20 cc, and dose at 50% of the parotid volume (D50) < 30 Gy. Biologically effective dose (BED) conversions with an α/β of 3 for normal parotid were performed to compare with 10-fraction and 15-fraction treatments of WBRT. The constraints are as follows: mean < BED 32.83 Gy, V15.76 (for 10-fraction WBRT) or V17.35 (for 15-fraction WBRT) < 20 cc, and D50 < BED 39.09 Gy. Nineteen patients treated to C1 and 26 patients treated to C2 were analyzed. Comparing WBRT to C1 with WBRT to C2, the mean left, right, and both parotids' doses were lower when treated to C1. Converting mean dose to BED3, the parotid doses were lower than BED3 constraint of 32.83 Gy: left (30.12 Gy), right (30.69 Gy), and both parotids (30.32 Gy). V20 to combined parotids was lower in patients treated to C1. When accounting for fractionation of WBRT received, the mean corrected V20 volume was less than 20 cc when treating to C1. D50 for C1 was lower than C2 for the left parotid, right parotid, and both parotids. BED3 conversion for the mean D50 of the left, right, and both parotids was less than 39.09 Gy. In conclusion, WBRT to C1 limits parotid dose, and parotid dose constraints are achievable compared with inferior border at C2. A possible mean parotid dose constraint with BED3 should be less than 32.83 Gy.
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Affiliation(s)
- Cheng-Chia Wu
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Yen-Ruh Wuu
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Ashish Jani
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Anurag Saraf
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Cheng-Hung Tai
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Matthew E Lapa
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Jacquelyn I S Andrew
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Akhil Tiwari
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Heva J Saadatmand
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032
| | - Steven R Isaacson
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032; Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032
| | - Simon K Cheng
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY 10032.
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Medical Center, 622 West 168th Street, BNH B-11, New York, NY 10032; Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY 10032.
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Essa H, Hamdy S. Evaluating the Scope of Gastrointestinal Symptoms of Parkinson's Disease: A Review of the Evidence. ACTA ACUST UNITED AC 2016. [DOI: 10.4303/ne/235955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Klingelhoefer L, Reichmann H. Parkinson’s Disease and Gastrointestinal Non Motor Symptoms: Diagnostic and Therapeutic Options – A Practise Guide. JOURNAL OF PARKINSONS DISEASE 2015; 5:647-58. [DOI: 10.3233/jpd-150574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Hawkey NM, Zaorsky NG, Galloway TJ. The role of radiation therapy in the management of sialorrhea: A systematic review. Laryngoscope 2015; 126:80-5. [PMID: 26152655 DOI: 10.1002/lary.25444] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2015] [Indexed: 12/11/2022]
Abstract
PURPOSE Up to 80% of patients with Parkinson disease and 30% of patients with amyotrophic lateral sclerosis (ALS) suffer from sialorrhea. Patients who fail medical and surgical therapy should be considered for external beam radiation therapy (EBRT). In this study, we conduct a systematic review to determine the dose and techniques used that result in greatest efficacy and lowest toxicity for the administration of EBRT in patients with Parkinson disease or ALS-associated sialorrhea. METHODS AND MATERIALS This review included 216 patients from four prospective and six retrospective studies published from 1998 to 2014, with ALS or Parkinson disease who were treated with electron or photon EBRT for sialorrhea. RESULTS A total of 216 patients were treated with EBRT from 10 studies. The indication for EBRT was failure of alternative medical treatment in all ALS patients. For patients with Parkinson disease, EBRT was the primary mode of treatment in 68% of cases. Overall, 176 (81%) of 216 patients treated with EBRT for sialorrhea reported symptomatic improvement from baseline. The most common target was the inferior two-thirds of the bilateral parotid glands and the entire bilateral submandibular glands. The total number of patients who experienced short-term toxicity was 86 of 216 patients (40%). The total number of patients who experienced long-term toxicity was 24 of 207 (12%). CONCLUSIONS EBRT is an effective treatment for sialorrhea in patients suffering from ALS or Parkinson disease. Treatment to the bilateral submandibular glands and caudal parotid glands is the most common field arrangement.
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Affiliation(s)
- Nathan M Hawkey
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, U.S.A
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, U.S.A
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Disorders of the oral cavity in Parkinson's disease and parkinsonian syndromes. PARKINSONS DISEASE 2015; 2015:379482. [PMID: 25685594 PMCID: PMC4312641 DOI: 10.1155/2015/379482] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 12/30/2014] [Indexed: 12/16/2022]
Abstract
Awareness of nonmotor symptoms of Parkinson's disease is growing during the last decade. Among these, oral cavity disorders are, although prevalent, often neglected by the patients, their caregivers, and physicians. Some of these disorders include increased prevalence of caries and periodontal disease, sialorrhea and drooling, xerostomia, orofacial pain, bruxism, and taste impairment. Though many of these disorders are not fully understood yet and relatively few controlled trials have been published regarding their treatment, physicians should be aware of the body of evidence that does exist on these topics.
This paper reviews current knowledge regarding the epidemiology, pathophysiology, and treatment options of disorders of the oral cavity in Parkinson's disease patients.
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Miranda-Rius J, Brunet-Llobet L, Lahor-Soler E, Farré M. Salivary Secretory Disorders, Inducing Drugs, and Clinical Management. Int J Med Sci 2015; 12:811-24. [PMID: 26516310 PMCID: PMC4615242 DOI: 10.7150/ijms.12912] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/02/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Salivary secretory disorders can be the result of a wide range of factors. Their prevalence and negative effects on the patient's quality of life oblige the clinician to confront the issue. AIM To review the salivary secretory disorders, inducing drugs and their clinical management. METHODS In this article, a literature search of these dysfunctions was conducted with the assistance of a research librarian in the MEDLINE/PubMed Database. RESULTS Xerostomia, or dry mouth syndrome, can be caused by medication, systemic diseases such as Sjögren's Syndrome, glandular pathologies, and radiotherapy of the head and neck. Treatment of dry mouth is aimed at both minimizing its symptoms and preventing oral complications with the employment of sialogogues and topical acting substances. Sialorrhea and drooling, are mainly due to medication or neurological systemic disease. There are various therapeutic, pharmacologic, and surgical alternatives for its management. The pharmacology of most of the substances employed for the treatment of salivary disorders is well-known. Nevertheless, in some cases a significant improvement in salivary function has not been observed after their administration. CONCLUSION At present, there are numerous frequently prescribed drugs whose unwanted effects include some kind of salivary disorder. In addition, the differing pathologic mechanisms, and the great variety of existing treatments hinder the clinical management of these patients. The authors have designed an algorithm to facilitate the decision making process when physicians, oral surgeons, or dentists face these salivary dysfunctions.
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Affiliation(s)
- Jaume Miranda-Rius
- 1. Departament d'Odontostomatologia. Facultat d'Odontologia. Universitat de Barcelona, Barcelona, Spain
| | - Lluís Brunet-Llobet
- 2. Servei d'Odontologia. Hospital Sant Joan de Déu. Universitat de Barcelona, Barcelona, Spain
| | - Eduard Lahor-Soler
- 1. Departament d'Odontostomatologia. Facultat d'Odontologia. Universitat de Barcelona, Barcelona, Spain
| | - Magí Farré
- 3. Clinical Pharmacology Unit. Hospital Universitari Germans Trias i Pujol-IGTP and Hospital del Mar Medical Research Institute (IMIM). Facultat de Medicina. Universitat Autònoma de Barcelona, Barcelona, Spain
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Abstract
Dysphagia is defined as a 'difficulty in swallowing' and is commonly found in the general population, particularly in the elderly. This article gives an overview of the more frequently encountered swallowing disorders and provides advice on how to manage the dysphagic patient in the dental surgery. Clinical Relevance: By identifying patients with dysphagia and being aware of the potential problems that the clinician may experience when treating them, the risk of aspiration, choking and healthcare-acquired upper respiratory tract infections may be reduced.
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Radiation Therapy for Hypersalivation: A Prospective Study in 50 Amyotrophic Lateral Sclerosis Patients. Int J Radiat Oncol Biol Phys 2014; 88:589-95. [DOI: 10.1016/j.ijrobp.2013.11.230] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 10/31/2013] [Accepted: 11/17/2013] [Indexed: 11/22/2022]
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Ko SH, Shin YB, Min JH, Shin MJ, Chang JH, Shin YI, Ko HY. Botulinum toxin in the treatment of drooling in tetraplegic patients with brain injury. Ann Rehabil Med 2013; 37:796-803. [PMID: 24466514 PMCID: PMC3895519 DOI: 10.5535/arm.2013.37.6.796] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 08/12/2013] [Indexed: 11/16/2022] Open
Abstract
Objective To investigate the effect of botulinum toxin type A (BTA) injection into the salivary gland and to evaluate the changes of drooling in varied postures in tetraplegic patients with brain injury. Methods Eight tetraplegic patients with brain injury were enrolled. BTA was injected into each parotid and submandibular gland of both sides under ultrasonographic guidance. Drooling was measured by a questionnaire-based scoring system for drooling severity and frequency, and the sialorrhea was measured by a modified Schirmer test for the patients before the injection, 3 weeks and 3 months after the injection. Drooling was evaluated in each posture, such as supine, sitting, and tilt table standing, and during involuntary mastication, before and after the injection. Results The severity and frequency of drooling and the modified Schirmer test improved significantly at 3 weeks and 3 months after the injection (p<0.05). Drooling was more severe and frequent in tilt table standing than in the sitting position and in sitting versus supine position (p<0.05). The severity of drooling was significantly increased in the patients with involuntary mastication (p<0.05). Conclusion Salivary gland injection of BTA in patients with tetraplegia resulting from brain injury who had drooling and sialorrhea could improve the symptoms for 3 months without complications. The severity and frequency of drooling were dependent on posture and involuntary mastication. Proper posture and involuntary mastication of the patients should be taken into account in planning drooling treatment.
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Affiliation(s)
- Sung Hwa Ko
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Yong Beom Shin
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Ji Hong Min
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Myung Jun Shin
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jae Hyeok Chang
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Yong-Il Shin
- Department of Rehabilitation Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Hyun-Yoon Ko
- Department of Rehabilitation Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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Salivary glands radiotherapy to reduce sialorrhea in amyotrophic lateral sclerosis: Dose and energy. Cancer Radiother 2013; 17:191-5. [DOI: 10.1016/j.canrad.2013.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 01/01/2013] [Accepted: 01/09/2013] [Indexed: 12/11/2022]
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Lakraj AA, Moghimi N, Jabbari B. Sialorrhea: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins (Basel) 2013; 5:1010-31. [PMID: 23698357 PMCID: PMC3709276 DOI: 10.3390/toxins5051010] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/09/2013] [Accepted: 04/24/2013] [Indexed: 12/14/2022] Open
Abstract
Sialorrhea or excessive drooling is a major issue in children with cerebral palsy and adults with neurodegenerative disorders. In this review, we describe the clinical features, anatomy and physiology of sialorrhea, as well as a review of the world literature on medical treatment using Yale University’s search engine; including but not limited to Medline and Erasmus. Level of drug efficacy is defined according to the guidelines of American Academy of Neurology. Current medical management is unsatisfactory. Topical agents (scopolamine and tropicamide) and oral agents (glyccopyrolate) combined render a level B evidence (probably effective); however, this treatment is associated with troublesome side effects. Double-blind and placebo-controlled studies of botulinum toxin (BoNT) provide a level A evidence for type B (two class I studies; effective and established) and both overall and individual B level of evidence for OnabotulinumtoxinA (A/Ona) and AbobotulinumtoxinA (A/Abo); these are probably effective. For IncobotulinumtoxinA (A/Inco), the level of evidence is U (insufficient) due to lack of blinded studies. Side effects are uncommon; transient and comparable between the two types of toxin. A clinical note at the end of this review comments on fine clinical points. Administration of BoNTs into salivary glands is currently the most effective way of treating sialorrhea.
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Affiliation(s)
- Amanda Amrita Lakraj
- Department of Neurology, Yale School of Medicine, 15 York Street LLCI-920 New Haven, CT 06520, USA; E-Mail:
| | - Narges Moghimi
- Department of Neurology, Case Western Reserve University; Cleveland, OH 44106, USA; E-Mail:
| | - Bahman Jabbari
- Department of Neurology, Yale School of Medicine, 15 York Street LLCI-920 New Haven, CT 06520, USA; E-Mail:
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-203-737-2464; Fax: +1-203-737-1122
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Abstract
Amyotrophic lateral sclerosis (ALS), the most common adult motor neuron disease, is an acquired disorder that results in loss of function in multiple domains. Although there is no treatment that can halt or reverse this progressive condition, there are many opportunities for interventions that can lead to improved quality of life for the patient and caregiver. Physical and occupational therapy can assist with mobility and activities of daily living. Interventions by speech pathology can optimize nutrition and communication. Respiratory function can be managed noninvasively or invasively. Depression, hopelessness, anxiety, and other mental health issues can and should be aggressively addressed and treated. Many symptoms such as pseudobulbar affect, sialorrhea, constipation, spasticity, and cramps can be treated effectively with medications. Spirituality and religion are important issues to address, as are end-of-life concerns, including advance directives, hospice, and the dying process. In contrast to the discouraging view that "there is nothing we can do," a broad approach to management, through collaboration with a multidisciplinary team, will permit the ALS physician to make a meaningful difference in the lives of individuals living with ALS.
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Affiliation(s)
- Zachary Simmons
- Department of Neurology, Pennsylvania State University College of Medicine, Hershey, PA, USA.
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Vashishta R, Nguyen SA, White DR, Gillespie MB. Botulinum Toxin for the Treatment of Sialorrhea. Otolaryngol Head Neck Surg 2012; 148:191-6. [DOI: 10.1177/0194599812465059] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Botulinum toxin has emerged as an effective approach for the management of sialorrhea. This study presents a critical literature review and meta-analysis to determine the impact of botulinum toxin on drooling severity in patients with sialorrhea. Data Sources Ovid MEDLINE and the Cochrane databases. Review Methods The above sources were searched to identify studies examining botulinum toxin for the treatment of sialorrhea. Included studies were randomized, placebo-controlled trials. Excluded studies failed to report quantifiable outcome measures of drooling severity at 4 weeks postintervention. Results Eight studies involving 181 patients (83 placebo; 98 active) were included in the analysis. Botulinum toxin was found to significantly decrease the severity of drooling in patients with sialorrhea (standardized mean difference [SMD], −1.54; 95% confidence interval [CI], −2.05 to −1.04; P = .06; I2 = 48%) when compared with placebo control using random effects models. The effect was significant in both adult (SMD, −1.29; 95% CI, −1.88 to −0.71) and pediatric (SMD, −1.84; 95% CI, −2.67 to −1.00) populations. Both botulinum toxin A (SMD, −1.53; 95% CI, −2.27 to −0.79) and B (SMD, −1.56; 95% CI, −2.32 to −0.79) produced similar effects. Botulinum toxin doses greater than 50 U (SMD, −3.81; 95% CI, –6.19 to −1.43) produced much stronger effects compared with doses less than or equal to 50 U (SMD, −1.32; 95% CI, −2.28 to −0.36). Conclusion Botulinum toxin is a clinically effective therapy that improves drooling severity in patients with sialorrhea. Future studies will need to further evaluate the technique and examine dosages required to achieve optimal outcomes.
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Affiliation(s)
- Rishi Vashishta
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A. Nguyen
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David R. White
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - M. Boyd Gillespie
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Loos G, Paulon R, Verrelle P, Lapeyre M. [Whole brain radiotherapy for brain metastases: the technique of irradiation influences the dose to parotid glands]. Cancer Radiother 2012; 16:136-9. [PMID: 22405693 DOI: 10.1016/j.canrad.2011.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Revised: 11/17/2011] [Accepted: 11/23/2011] [Indexed: 10/28/2022]
Abstract
In the treatment of brain metastases, whole brain radiotherapy can be carried out according two distinct methods: one using multileaf collimator for field shaping and protection of organs at risk, and a second one is to make a rotation of the field to avoid the eyes. The aim of the study was to compare for 10 patients the dose distributions at organs at risk for each method. Patients received 30 Gy in 10 fractions. Except for parotid glands, the dose received by organs at risk and the planning target volume was the same with each method. For whole brain radiotherapy, excluding the cisterna cerebellomedullaris, the mean parotid dose was 9.63 Gy using the multileaf collimator versus 12.32 Gy using the field rotation (P=0.04). For whole brain radiotherapy including the cisterna cerebellomedullaris, the mean parotid dose was 11.12 Gy using the multileaf collimator versus 20.06 Gy using field rotation (P<0.001). Using the multileaf collimator seems recommended for whole brain radiotherapy, to reduce the dose to the parotids.
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Affiliation(s)
- G Loos
- Département de radiothérapie, centre Jean-Perrin, Clermont-Ferrand, France.
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Kasarskis EJ, Hodskins J, Clair WHS. Unilateral parotid electron beam radiotherapy as palliative treatment for sialorrhea in amyotrophic lateral sclerosis. J Neurol Sci 2011; 308:155-7. [DOI: 10.1016/j.jns.2011.06.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 06/02/2011] [Accepted: 06/07/2011] [Indexed: 12/11/2022]
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Guy N, Bourry N, Dallel R, Dualé C, Verrelle P, Lapeyre M, Clavelou P. Comparison of Radiotherapy Types in the Treatment of Sialorrhea in Amyotrophic Lateral Sclerosis. J Palliat Med 2011; 14:391-5. [DOI: 10.1089/jpm.2010.0308] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nathalie Guy
- Université d'Auvergne, Clermont Ferrand, France
- Inserm, U929, Neurobiologie de la Douleur Trigéminale, Clermont Ferrand, France
- CHU de Clermont Ferrand, Service de neurologie, Centre SLA, Clermont Ferrand, France
| | | | - Radhouane Dallel
- Université d'Auvergne, Clermont Ferrand, France
- Inserm, U929, Neurobiologie de la Douleur Trigéminale, Clermont Ferrand, France
| | - Christian Dualé
- Université d'Auvergne, Clermont Ferrand, France
- Inserm, U929, Neurobiologie de la Douleur Trigéminale, Clermont Ferrand, France
- CHU de Clermont Ferrand, Inserm CIC 501, Clermont Ferrand, France
| | | | | | - Pierre Clavelou
- Université d'Auvergne, Clermont Ferrand, France
- Inserm, U929, Neurobiologie de la Douleur Trigéminale, Clermont Ferrand, France
- CHU de Clermont Ferrand, Service de neurologie, Centre SLA, Clermont Ferrand, France
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Abstract
A 45-year-old patient presented with refractory salivary fistula, attributed to multiple surgery and Botulinum toxin, following lateral parotidectomy. He underwent fractionated radiotherapy of the remaining parotid gland including the fistula opening (total dose of 30 Gy) at our clinic. In time, fistula secretion could be inhibited completely. Although the indication for radiotherapy for such fistulas is rare since Botulinum toxin has been in use, it should still be considered in refractory disease courses.
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Abstract
BACKGROUND More than 1.5 million Americans have Parkinson disease (PD), and this figure is expected to rise as the population ages. However, the dental literature offers little information about the illness. TYPES OF STUDIES REVIEWED The authors conducted a MEDLINE search using the key terms "Parkinson's disease," "medical management" and "dentistry." They selected contemporaneous articles published in peer-reviewed journals and gave preference to articles reporting randomized controlled trials. RESULTS PD is a progressive neurodegenerative disorder caused by loss of dopaminergic and nondopaminergic neurons in the brain. These deficits result in tremor, slowness of movement, rigidity, postural instability and autonomic and behavioral dysfunction. Treatment consists of administering medications that replace dopamine, stimulate dopamine receptors and modulate other neurotransmitter systems. CLINICAL IMPLICATIONS Oral health may decline because of tremors, muscle rigidity and cognitive deficits. The dentist should consult with the patient's physician to establish the patient's competence to provide informed consent and to determine the presence of comorbid illnesses. Scheduling short morning appointments that begin 90 minutes after administration of PD medication enhances the patient's ability to cooperate with care. Inclination of the dental chair at 45 degrees, placement of a bite prop, use of a rubber dam and high-volume oral evacuation enhance airway protection. To avoid adverse drug interactions with levodopa and entacapone, the dentist should limit administration of local anesthetic agents to three cartridges of 2 percent lidocaine with 1:100,000 epinephrine per half hour, and patients receiving selegiline should not be given agents containing epinephrine or levonordefrin. The dentist should instruct the patient and the caregiver in good oral hygiene techniques.
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Stone CA, O'Leary N. Systematic review of the effectiveness of botulinum toxin or radiotherapy for sialorrhea in patients with amyotrophic lateral sclerosis. J Pain Symptom Manage 2009; 37:246-58. [PMID: 18676117 DOI: 10.1016/j.jpainsymman.2008.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 02/11/2008] [Accepted: 02/18/2008] [Indexed: 12/12/2022]
Abstract
Fifty percent of patients with amyotrophic lateral sclerosis (ALS) experience problems handling serous saliva and 20% fail to achieve adequate control of sialorrhea with anticholinergic medications, or experience intolerable adverse effects from these drugs. Both botulinum and radiotherapy have been suggested in the literature as treatments for intractable sialorrhea. In this review, we assess the evidence for the effectiveness and toxicity of botulinum toxin and radiotherapy for sialorrhea in patients with ALS. Relevant studies were retrieved from Medline, Embase and Cochrane Databases. Handsearching of Neurology, Journal of Pain and Symptom Management, and Palliative Medicine and of reference lists, was carried out. Five studies (28 patients) were included in the analysis of botulinum. Of the four studies using an intraglandular method of injection, no adverse effects occurred. Two of these had positive findings of the effect of botulinum in salivary secretion rate and quality of life. In contrast, significant adverse effects were experienced by two patients in a study of retrograde injections into the salivary ducts. Two studies were included in the analysis of radiotherapy (27 patients). Both demonstrated a positive effect of radiotherapy on salivary secretion rate. Some patients experienced mild acute side effects. Because of the small numbers of studies, small sample sizes, and poor quality of reporting, it is not possible to draw firm conclusions. There is some evidence indicating that both botulinum and radiotherapy are well tolerated, effective treatments for persistent sialorrhea in patients with ALS and that the duration of action is up to three months with botulinum and six months with radiotherapy.
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Shama L, Connor NP, Ciucci MR, McCulloch TM. Surgical treatment of dysphagia. Phys Med Rehabil Clin N Am 2008; 19:817-35, ix. [PMID: 18940643 DOI: 10.1016/j.pmr.2008.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The role of surgery in the management of dysphagia is clear in some areas and controversial in others. Evaluation for the causes of dysphagia can elucidate conditions in which surgery can improve safety, quality of life, or both. Surgical therapy, when indicated, is safe and effective for many causes of dysphagia. This article includes a general overview of the causes of dysphagia that can be addressed successfully with surgery as well as a discussion of why surgery may be less appropriate for other conditions associated with dysphagia.
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Affiliation(s)
- Liat Shama
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-7373, USA
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Postma AG, Heesters M, van Laar T. Radiotherapy to the salivary glands as treatment of sialorrhea in patients with parkinsonism. Mov Disord 2008; 22:2430-5. [PMID: 17960826 DOI: 10.1002/mds.21752] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This study investigated retrospectively the long-term efficacy and safety of radiotherapy (RT) to the major salivary glands as treatment of sialorrhea in patients with parkinsonism. Twenty-eight patients received a bilateral dose of 12 Gy to the parotid and part of the submandibular glands between 2001 and 2006. Severity of sialorrhea and adverse events were assessed at 1 and 6 months post-RT and finally in the first quarter of 2007. Item 6 of the activities of daily living-section of the Unified Parkinson's Disease Rating Scale was used as primary endpoint. Quality of life (QoL) pre- and post-RT was investigated using a shortened Parkinson's Disease Questionnaire-8. Sialorrhea had improved significantly at 1 month post-RT and this effect was maintained for at least 1 year. Most frequent adverse events were loss of taste and a dry mouth; however, 75% of these adverse events were transient. QoL had improved significantly on the long term. The clinical global impression scores at the final follow-up showed that 80% of patients were satisfied. It was concluded that RT is an effective and safe treatment of sialorrhea on the long term in patients with parkinsonism.
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Affiliation(s)
- Anna-Gerlind Postma
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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29
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Abstract
(1) Sialorrhoea is a common condition in patients with Parkinson's disease that has a negative impact on patient quality of life. (2) Traditionally, muscarinic antagonists have been the pharmacological agents of choice for the treatment of sialorrhoea; however, these agents are frequently associated with adverse events in patients with Parkinsonian disorders. (3) Recent studies suggest that botulinum toxin injection is currently the most effective treatment option for Parkinsonian-related sialorrhoea.
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Affiliation(s)
- Luke Molloy
- Wolters Kluwer Health/Adis, Auckland, New Zealand
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30
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Elman LB, Houghton DJ, Wu GF, Hurtig HI, Markowitz CE, McCluskey L. Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis. J Palliat Med 2007; 10:433-57. [PMID: 17472516 DOI: 10.1089/jpm.2006.9978] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders. OBJECTIVES The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms. DESIGN The authors review current management and the supporting literature. CONCLUSIONS Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.
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Affiliation(s)
- Lauren B Elman
- ALS Association Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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31
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Abstract
A significant number of patients with Parkinson's disease (PD) experience sialorrhea. This problem can cause social embarrassment, and because saliva pools in the mouth, may lead to aspiration pneumonia. Sialorrhea in PD is thought to be caused by impaired or infrequent swallowing, rather than hypersecretion. Oral medications, botulinum toxin injections, surgical interventions, radiotherapy, speech therapy, and trials of devices may be used to treat sialorrhea in PD, but few controlled trials have been published. This article reviews current knowledge regarding the frequency, etiology, assessment, and treatment of sialorrhea in PD.
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Affiliation(s)
- Kelvin L Chou
- Department of Clinical Neurosciences, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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Puraviappan P, Dass DB, Narayanan P. Efficacy of Relocation of Submandibular Duct in Cerebral Palsy Patients with Drooling. Asian J Surg 2007; 30:209-15. [PMID: 17638641 DOI: 10.1016/s1015-9584(08)60024-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE The efficacy of relocating the submandibular duct to treat drooling in children with cerebral palsy was studied. METHODS This was a prospective study to assess, using a visual analogue score by the parents of the patients, the efficacy of relocating the submandibular duct to treat drooling, comparing pre- and postoperative drooling. Complications were also recorded. RESULTS Eight children were included in this study. Their mean age was 9.75 years (range, 6-14 years). Seven patients (87.5%) had significant reduction of drooling (from a score of > or = 7 before surgery to < or = 2 after surgery). All the parents of the eight children (100%) were happy with the outcome and would recommend the procedure to the parents of other children. Mean length of hospital stay was 4 days (range, 2-7 days). Three patients developed complications; one patient developed ranula 1 month postoperatively. This was successfully treated by marsupialization. Two patients developed bilateral submandibular sialoadenitis 3 days postoperatively, which resolved with antibiotic therapy. CONCLUSION We conclude that this procedure is effective and safe in reducing drooling in patients with cerebral palsy.
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Abstract
PURPOSE OF REVIEW Drooling is the involuntary spillage of saliva from the mouth. It is a major morbidity associated with cerebral palsy and other neurodegenerative disorders. The consequences of drooling are not restricted to medical issues but can cause major social handicaps. Severe psycho-social consequences, such as social stigmatization and emotional devastation for the patients and their families, may result. This paper reviews recent developments in the management of drooling. RECENT FINDINGS Recent publications report encouraging results with botulinum toxin A. Several surgeons report on their long-term results. Reviews analyze anticholinergic drugs, surgical options, biofeedback, behavioral and speech therapy, and a multidisciplinary team approach. SUMMARY A team approach is the key to successful rehabilitation. Oromotor therapy is the most useful nonsurgical option. Drugs are unsuitable for long-term use due to adverse effects causing serious medical complications or noncompliance. Botulinum toxin A injection is promising, but no data exists on optimal dosage, duration of action and frequency of repeat injections. Bilateral submandibular duct relocation with bilateral sublingual gland excision has been shown to be effective and safe in long-term follow-up of the largest series of patients. At present, it is the best available surgical option.
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Affiliation(s)
- Devyani Lal
- Department of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
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Abstract
An exhaustive review of the literature shows the very relative efficiency of diverse treatments for chronic drooling. Morbidity is too high with medical treatments and behavioral treatments require active collaboration from the patient. The different surgical techniques, either based on derivation or ligature of the principal salivary ducts combined with glandular tissue extirpation, are not free of complications. There is much controversy over their efficiency due to the lack of sound evidence. Caution is therefore primordial before proposing surgery for chronic drooling: the available surgical procedures all have technical limitations and clinical trials have demonstrated many failures. At the most, the patient can expect a 50 to a maximum 80% reduction of drooling.
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Affiliation(s)
- H Reychler
- Service de Stomatologie et Chirurgie Maxillo-faciale, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Bruxelles, Belgique.
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De Simone GG, Eisenchlas JH, Junin M, Pereyra F, Brizuela R. Atropine drops for drooling: a randomized controlled trial. Palliat Med 2006; 20:665-71. [PMID: 17060265 DOI: 10.1177/0269216306071702] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Drooling occasionally occurs in cancer patients, impairing their quality of life. Recommended treatment includes the use of anticholinergic drugs, but there is a lack of scientific evidence supporting it; some recent reports tested the use of sublingual atropine, and further controlled studies have been recommended. OBJECTIVE To evaluate the effectiveness of sublingual atropine for the relief of drooling when compared with a placebo, in a population of patients with upper digestive cancer at the Gastroenterology 'Bonorino Udaondo' Hospital. POPULATION AND METHODOLOGY From March 2002 to March 2003, 22 consecutive patients were enrolled in a prospective, randomized, placebo-controlled, double-blind, cross-over trial (gender: M/F=14/8; median age=66, range: 4887 years). Patients were randomly allocated to receive atropine or placebo for 48 hours (phase 1), followed by a wash-out period of 48 hours, and final cross-over during the next 48 hours (phase 2). We evaluated the impact on sialorrhoea, choking, interference with daily and social activities, and global impact from drooling by visual analogue scales (VAS) at the beginning and end of each phase, as well as patients' choice at the end of the study. RESULTS Mean score for sialorrhoea was 59.6 (SD=28.5) at baseline and 34.9 (SD=27.7) after 48 hours of receiving atropine; 62.1 (SD=27.6) at baseline and 40.7 (SD=30.5) after 48 hours of placebo. Analysis of variance (ANOVA) for repeated measures and two factors was not significant for either the variable sialorrhoea (P=0.58) or any of the secondary outcomes measured. No severe toxicity was reported. CONCLUSIONS This study failed to demonstrate the effectiveness of atropine over placebo in this population; we provide further discussion of results.
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Affiliation(s)
- Gustavo G De Simone
- Palliative Care Service, Hospital Bonorino Udaondo and Pallium Latinoamerica, Buenos Aires
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36
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Quels sont les traitements medicamenteux symptomatiques? Rev Neurol (Paris) 2006. [DOI: 10.1016/s0035-3787(06)75192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Meningaud JP, Pitak-Arnnop P, Chikhani L, Bertrand JC. Drooling of saliva: A review of the etiology and management options. ACTA ACUST UNITED AC 2006; 101:48-57. [PMID: 16360607 DOI: 10.1016/j.tripleo.2005.08.018] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Revised: 07/20/2005] [Accepted: 08/17/2005] [Indexed: 10/25/2022]
Abstract
Drooling of saliva appears to be the consequence of a dysfunction in the coordination of the swallowing mechanism, resulting in excess pooling of saliva in the anterior portion of the oral cavity and the unintentional loss of saliva from the mouth. Drooling can produce significant negative effects on physical health and quality of life, especially in patients with chronic neurological disabilities. Various approaches to manage this condition have been described in the literature, including oral motor therapy, behavior modification via biofeedback, orofacial regulation therapy, drug therapy, radiotherapy, and surgical treatments. Minimally invasive modalities, such as injection of botulinum toxin, photocoagulation, and acupuncture, have also been reported. This article provides a comprehensive and thorough overview of drooling, with an emphasis on understanding its etiologies and modalities of treatment.
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Affiliation(s)
- Jean-Paul Meningaud
- Department of Maxillofacial Surgery, Teaching Pitié-Salpêtrière Hospital, Paris, France.
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Simmons Z. Management strategies for patients with amyotrophic lateral sclerosis from diagnosis through death. Neurologist 2005; 11:257-70. [PMID: 16148733 DOI: 10.1097/01.nrl.0000178758.30374.34] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disorder that is inevitably fatal. There are no effective treatments to stop or reverse the natural course of the disease. The role of the physician is to provide comfort and optimize quality of life. REVIEW SUMMARY Management of patients with ALS is a process extending over months to years. It begins with breaking the news of the diagnosis and extends through the terminal phase. Medication may extend lifespan by a small amount. However, most efforts are centered around symptom management. Areas of importance include respiration, nutrition, secretions, communication, pseudobulbar affect, therapy and exercise, spasticity and cramps, pain, depression and suicide, spirituality and religion, cognitive changes, the development of advance directives, and care at the end of life. Multidisciplinary ALS clinics provide much-needed support for patients with ALS and their caregivers. CONCLUSION Although physicians cannot cure ALS or even halt progression, there is much that can be done to manage the physical and emotional symptoms, thereby maintaining or enhancing quality of life.
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Affiliation(s)
- Zachary Simmons
- Department of Neurology, Penn State College of Medicine, Hershey, 17033, USA.
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Elman LB, Dubin RM, Kelley M, McCluskey L. Management of Oropharyngeal and Tracheobronchial Secretions in Patients with Neurologic Disease. J Palliat Med 2005; 8:1150-9. [PMID: 16351528 DOI: 10.1089/jpm.2005.8.1150] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Neurologic disorders may impair the normal clearance of secretions. Effective palliation requires the management of excessive oral, pharyngeal and/or tracheobronchial secretions. This requires an understanding of underlying mechanisms and familiarity with the many available medical and surgical treatment options. OBJECTIVES The authors intend to review the relevant anatomy and physiology along with the available medical, surgical and physical therapies available to treat this commonly encountered problem. DESIGN A review of current management and the supporting literature. CONCLUSIONS Clinicians have many effective therapeutic options to choose from when managing the excessive oral, pharyngeal and/or tracheobronchial secretions caused by neurologic disorders. Treatment choices that are predicated upon pathophysiologic causes and patient status are the most likely to succeed.
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Affiliation(s)
- Lauren B Elman
- Department of Neurology, Division of Speech and Language Pathology, Philadelphia, Pennsylvania, USA
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Dogu O, Apaydin D, Sevim S, Talas DU, Aral M. Ultrasound-guided versus 'blind' intraparotid injections of botulinum toxin-A for the treatment of sialorrhoea in patients with Parkinson's disease. Clin Neurol Neurosurg 2004; 106:93-6. [PMID: 15003297 DOI: 10.1016/j.clineuro.2003.10.012] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/29/2003] [Accepted: 10/21/2003] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To investigate the efficacy and safety of intraparotid botulinum toxin-A (BTX-A) injections into parotid gland using ultrasound-guided versus nonguided techniques for the treatment of sialorrhoea in patients with Parkinson's disease (PD). METHODS 15 patients with PD and sialorrhoea were included and divided into two groups. Group A patients (n=8) were injected with BTX-A using ultrasound guidance. Group B patients (n=7) were injected with BTX-A without ultrasound guidance. Saliva secretion was assessed quantitatively at baseline and at weeks 1, 4, and 12. Patients and/or caregivers also assessed the saliva secretion using visual analog scale (VAS). RESULTS All patients except one reported subjective improvement in sialorrhoea at the first week. Group A patients showed significantly higher rate of saliva reduction at the first week, whereas in Group B the reduction was not statistically significant from baseline at the first week (P>0.05). Comparisons of quantitative saliva assessments at each follow-up visit also showed that ultrasound-guided injections were superior to blind injections for saliva reduction. VAS scores showed an improvement in the mean rate of saliva secretion in each group at first week (P<0.05). Two patients suffered from dry mouth in mild severity lasting 1 month. CONCLUSION Intraparotid BTX-A injections using ultrasound guidance may be an effective, easy, and safe treatment for parkinsonian sialorrhoea.
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Affiliation(s)
- Okan Dogu
- Department of Neurology, Faculty of Medicine, Tip Fakultesi Hastanesi, Noroloji Anabilim Dali, Zeytinlibahce cad., Mersin Universitesi, 33070 Mersin, Turkey.
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Stalpers LJA, Moser EC. Results of radiotherapy for drooling in amyotrophic lateral sclerosis. Neurology 2002; 58:1308. [PMID: 11971112 DOI: 10.1212/wnl.58.8.1308] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lukas J A Stalpers
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, the Netherlands.
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Andersen PM, Grönberg H, Franzen L, Funegård U. External radiation of the parotid glands significantly reduces drooling in patients with motor neurone disease with bulbar paresis. J Neurol Sci 2001; 191:111-4. [PMID: 11677000 DOI: 10.1016/s0022-510x(01)00631-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The parotid glands and part of the submandibular glands were irradiated in 18 amyotrophic lateral sclerosis patients with very advanced disease and severe drooling problems. In a prospective study, a single dosage of 7.0-7.5 Gy was administered bilateral to the larger part of the parotid glands and the posterior parts of the submandibular glands. Salivary secretion rate was assayed before and after radiotherapy. Sixteen out of eighteen patients reported satisfactory to good reduction in drooling lasting up to 4-6 months, 1/18 developed xerostomia and needed saliva substitutes, and 1/18 reported no effect. Caregivers reported positive effect in all patients. The procedure was well tolerated with few side effects. Low dosage external radiotherapy of the salivary glands is effective in reducing drooling satisfactorily in ALS patients, especially in well-hydrated patients.
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Affiliation(s)
- P M Andersen
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden.
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