Dental health of children with cerebral palsy following sialodochoplasty

Risk Factors for Dental Caries Experience in Children and Adolescents with Cerebral Palsy—A Scoping Review

Cerebral palsy is a developmental motor disorder which has far-reaching impacts on oral health. This scoping review examined the extent of research undertaken regarding the risk factors affecting dental caries experience in children and adolescents with cerebral palsy. Data were obtained from the electronic databases Web of Science and PubMed, using 10 search strings, for studies published between 1983 and 2018. Eligible studies were required to have investigated caries in children under 18 with cerebral palsy, as well as be written in English. 30 papers published were identified for inclusion in the review. These included 23 cross-sectional, 6 case–control, and 1 longitudinal study. Studies were categorized into six domains of risk factors: socioeconomic status (SE); cerebral palsy subtype (CPS); demographics (D); condition of oral cavity (OC); dental habits (DH); nutrition and diet (ND). This review was conducted and reported in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The most significant risk factors were caregiver-related education levels, oral health literacy, and sugar intake; this underlines the important role of special education and dental awareness in reducing dental caries incidence in CP children. Other factors showed divergent findings, highlighting the need for standardization and culturally specific studies in future literature.

Anticholinergic medications for reducing drooling in children with developmental disability

AIM

To determine: the effectiveness of three anticholinergic medications in reducing drooling in children with developmental disabilities (such as cerebral palsy, intellectual disability, and autism spectrum disorder), the frequency and nature of side effects, and their impact on treatment discontinuation.

METHOD

After prescription of benzhexol hydrochloride, glycopyrrolate, or scopolamine patches at a tertiary saliva control clinic, all carers of 110 consecutive, eligible patients were recruited over a 5-year period. They provided data for 52 weeks, or until drug discontinuation, on compliance, drooling, adverse effects, and reasons for cessation. We evaluated and compared best drooling response, side effects, and drug cessation rates using survival analysis, and the effect of baseline variables on the discontinuation rate using proportional hazards regression.

RESULTS

Among 110 participants (71 males, 39 females; mean age 8y 5mo [SD 4y 3mo], range 1y 11mo-18y 11mo), benzhexol, glycopyrrolate, and scopolamine were prescribed 81, 62, and 17 times respectively, with respective response rates of 85%, 75%, and 65%. Poor head control and poor oromotor function were predictive of poor response. Side effects frequently prompted drug cessation in males more than females (hazard ratio 1.8 [95% confidence interval 1.0-3.2], p=0.048). Glycopyrrolate had the fewest side effects.

INTERPRETATION

Benzhexol, glycopyrrolate, and scopolamine reduce drooling, but improvement is offset by adverse side effects. Overall, glycopyrrolate performs best.

WHAT THIS PAPER ADDS

In drooling, glycopyrrolate produced the greatest improvement with fewer side effects compared with benzhexol and scopolamine. Poor head control and poor oromotor function were associated with poor response. Medication side effects were common and often led to treatment discontinuation. Behavioural issues instigated cessation of benzhexol more often in males than females.

The burden of sialorrhoea in chronic neurological conditions: current treatment options and the role of incobotulinumtoxinA (Xeomin®)

Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson’s disease, motor neuron disease, cerebral palsy, and stroke) and is defined as excessive saliva accumulation leading to unintentional loss of saliva from the mouth. Sialorrhoea increases the overall burden on the patient and their caregivers, the impact of which can be both physical and psychosocial. Treatments for sialorrhoea range from lifestyle and behavioural guidance, to medications, surgery or radiation. Nonpharmacological interventions include advice on posture, swallowing control, cough management, dietary changes, eating and drinking techniques, and behavioural modification; however, these conservative measures may be ineffective for people with progressive neurological conditions. The pharmacological treatment of sialorrhoea is challenging because medications licensed for this purpose are limited, but treatments can include anticholinergic drugs and botulinum toxins. Surgical treatment of sialorrhoea is typically reserved as a last resort for patients. IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US and UK marketing authorization for the symptomatic treatment of chronic sialorrhoea due to neurological disorders in adults. In this review, we discuss and compare the frequency and method of administration, location of treatment delivery, approximate annual costs and main side effects of botulinum toxin and different anticholinergic drugs. Management of patients with chronic neurological conditions requires input from multiple specialist teams and thus a multidisciplinary team (MDT) approach is considered fundamental to ensure that care is consistent and tailored to patients’ needs. To ensure that adult patients with neurological conditions receive the best care and sialorrhoea is well managed, we suggest a potential clinical care pathway for sialorrhoea with a MDT approach, which healthcare professionals could aspire to.

Effects of treatments for drooling on caries risk in children and adolescents with cerebral palsy

Background

Neuromuscular impairment makes individuals with cerebral palsy (CP) more prone to drooling. Among the treatment options, there are procedures that interfere with saliva production. It is imperative to evaluate the effect of the different modalities since the reduction in salivary flow rate/production may exacerbate the risk of dental caries.

Material and Methods

The aim of this study was to compare the effects of different treatments for drooling on caries risk and salivary parameters in children and adolescents with CP.

Study design

A total of 142 children and adolescents with CP, aged 6 to 18 years, were assigned to groups based on the different treatments they had received for drooling: G1—anticholinergic drugs (n = 18), G2—botulinum toxin injection (n = 16), G3—salivary glands surgery (n = 16), G4—no treatment (n = 42), and G5—non-drooling subjects (n = 50). All participants were evaluated on the Simplified Oral Hygiene Index, and for the prevalence of dental caries (decayed, missing, and filled teeth index and white spot lesions). Unstimulated whole saliva was collected, and salivary flow rate and osmolality were measured. Chi-square, ANOVA and Poisson regression were calculated. Prevalence ratios and their respective 95 % confidence intervals were obtained. The significance level was fixed at 5%.

Results

No differences were found in the decayed, missing, and filled teeth index (p = 0.128) and Simplified Oral Hygiene Index (p = 0.674) among the different groups. G3 presented significantly higher percentages of WSL (p<0.001), lower values of salivary flow rate (p<0.001), and higher values of osmolality (p<0.001). The white spot lesion prevalence ratio was higher only for G3 (Prevalence ratio = 14.36; IC 95% = 4.64-44.40; p<0.001).

Conclusions

Children and adolescents with CP who had received surgical treatment for drooling exhibited higher number of white spot lesions because of the reduced salivary flow rate and higher salivary osmolality.

Key words:Cerebral palsy, saliva, sialorrhea, dental caries, osmolar concentration.

Diagnosis and Management of Drooling in Children With Progressive Dystonia: A Case Series of Patients With MEGDEL Syndrome

Drooling is a common problem in children with progressive dystonia. The authors noted a 58% incidence of drooling in 22/38 children with MEGDEL, a rare neurodegenerative cause of dystonia and report on the clinical course of four patients. Drooling of varying severity and subsequent respiratory problems were treated at the authors' multidisciplinary saliva-control outpatient clinic. One patient improved on antireflux medication, the second after medication with drooling as side effect was changed. Two other patients underwent salivary gland surgery, one of whom significantly improved; the other died shortly after surgery. The heterogeneity of the cases presented shows the need for stepwise and personalized treatment. The authors recommend the following: (1) optimize the treatment of the underlying neurological condition and replace medication that stimulates saliva secretion; (2) treat constipation, scoliosis, and gastroesophageal reflux if there is still a risk of chronic aspiration of saliva; (3) perform more intense/invasive treatment (botulinum toxin, salivary gland surgery).

Alterações sialoquímicas e sialométricas de pacientes com paralisia cerebral: uma revisão de literatura

TEMA: paralisia cerebral e alterações salivares. O paciente com paralisia cerebral é acometido por diversas desordens no Sistema Estomatognático, sendo muitas delas expressas sob a forma de alterações no fluxo e composição salivar. A variação da concentração de constituintes da saliva está diretamente relacionada com sua capacidade tampão, antioxidante, imunológica, digestiva e lubrificante, além de sofrer variações em função da velocidade do fluxo salivar, o qual está intimamente relacionado à eficiência dos estímulos mecânicos e neurais do trato salivar. Alterações na deglutição, da percepção gustativa, do processo de mineralização dos dentes e da propriedade protetora da saliva contra lesões cariosas, infecções e inflamações, freqüentemente observadas em pacientes com paralisia cerebral, podem ser avaliadas pelo exame da saliva. OBJETIVO: realizar uma revisão de literatura relacionando as principais alterações sialométrica e sialoquímica de pacientes com paralisia cerebral e seus efeitos na saúde bucal. CONCLUSÃO: a análise sialométrica e sialoquímica oferece informações extremamente úteis no diagnóstico e no direcionamento do tratamento desses pacientes, e pode ser considerada uma indicadora prática e objetiva dos processos de doença e disfunções.

The influence of valproic acid on salivary pH in children with cerebral palsy

The purpose of this open-label, crossover study was to measure salivary pH after the oral administration of distilled water, a 10% sucrose solution, and valproic acid to a population of 10 children with cerebral palsy. Salivary pH was measured just prior to giving the solutions and then every five minutes for 60 minutes. The critical pH was defined at 5.5, below which dental demineralization occurs. In this population, valproic acid decreased salivary pH to below the critical pH for an extended period of time (mean = 4.32 at 20 minutes) when compared to mean salivary pH after administration of distilled water (7.11 at 20 minutes) and a 10% sucrose solution (5.96 at 20 minutes). Recovery from this low pH to above the critical level did not occur until after 50 minutes and furthermore did not recover to baseline, neutral levels, for the duration of this study (60 minutes). Our results suggest that children with cerebral palsy, a population with a tendency toward reduced salivary function, have a compromised ability to buffer the oral administration of an exogenous acid. This can result in an increased susceptibility to demineralization and caries of the teeth.

Prospective analysis of the outcome of surgical management of drooling in the pediatric population: a 10-year experience

BACKGROUND

Sialorrhea is a common problem in the neurologically impaired pediatric patient and surgery is the mainstay of treatment for severely affected patients refractory to conservative or medical treatment.

METHODS

The results of the surgical protocol used since 1993 at the Royal Children's Hospital in Melbourne, Australia, are reported. Seventy-two patients underwent bilateral submandibular duct transposition combined with bilateral sublingual gland excision. Patients were analyzed prospectively and reviewed at 1, 6, and 12 months, then at 2 and 5 years postoperatively.

RESULTS

Of 67 patients with 2 years of complete follow-up, the median score for the frequency of drooling fell from 4.0 to 2.9 (p < 0.001) and the median severity-of-drooling score decreased from 4.8 to 3.0 (p < 0.001). There was a fall in the number of clothing/bib changes from a median of four per day to zero (p < 0.0001). Of 41 patients followed to 5 years, both the median frequency and severity of drooling scores remained at 3. Overall the majority of patients benefited from surgery. Thirteen patients (18 percent) experienced complications which were major in 9 percent.

CONCLUSION

We have found bilateral sublingual gland excision in combination with bilateral submandibular duct transposition to be superior to bilateral submandibular duct transposition plus parotid duct ligation. The surgical treatment of sialorrhea continues to be a rewarding experience for our multidisciplinary team.

Infantile reflexes and their effects on dental caries and oral hygiene in cerebral palsy individuals

The aim of this study was to evaluate the presence of pathological primitive reflexes and their effects on dental caries and oral hygiene in cerebral-palsied individuals. A group of 124 non-institutionalized patients (57 males) attending Lar Escola Sao Francisco Rehabilitation Center, who had a medical diagnosis of spastic CP (age range 3-17 years, mean+/-s.d.=8.6+/-4.3) were selected for dental clinical evaluation according to WHO (Oral health surveys: basic methods, WHO, Geneva, 1997) and oral hygiene using the oral hygiene index proposed by Greene and Vermillion (J Am Dent Assoc, 1964, 68, 7). The presence/absence of the pathological primitive oral reflexes of rooting, suckle-swallow, biting and gagging was evaluated by observing patients' reaction after a stimulus. Results were statistically analysed by Fisher's exact, Chi-square and Kruskal-Wallis tests. A significantly higher percentage of the biting reflex in patients with quadriplegia was observed, and also the absence of this reflex in patients with hemiplegia (P=0.006). Patients with hemiplegia presented significantly lower DMF index values. Kruskal-Wallis test showed no statistical difference (P=0.335; 0.677; 0.202) for OHI-S among the quadriplegia, diplegia and hemiplegia for all dentitions. Our data suggest that the more severe the neurological damage is, the more frequent is the presence of the biting reflex and consequently, the higher is the risk of oral diseases in this population due to the difficulty to perform an adequate oral hygiene.

Submandibular gland aplasia and progressive dental caries: a case report

When severe caries occurs in mandibular permanent incisor teeth, the clinician should consider the possibility of associated submandibular gland aplasia or salivary hypofunction. Early diagnosis of submandibular gland disease is essential, as operative problems involving restoration of mandibular incisor teeth are considerable. Furthermore, progressive severe dental caries can present a dilemma for the clinician in affected individuals, despite intensive preventive and restorative therapy. A case report describing severe progressive dental caries and enamel demineralization of the permanent mandibular incisor teeth in a young girl is presented. Further investigation revealed absence of functional bilateral submandibular salivary glands contributing to the rapid breakdown of the teeth despite intensive preventive measures.