ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 SIALORRHEA: CHALLENGES AND MANAGEMENT Mahima Sehgal1, Dr. Suwarna Dangore2, Radha Goverdhan3, Mahwish Nida4 1Intern, Sharad Pawar Dental College & Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra. India 2Professor, Department of Oral Medicine and Radiology, Sharad Pawar Dental College & Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra. India 3Intern, Sharad Pawar Dental College & Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra. India 4Intern, Sharad Pawar Dental College & Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra. India

E-mail : [email protected]

Received: 14 April 2020 Revised and Accepted: 8 August 2020 ABSTRACT : In a conscious person, saliva is continuously produced. Saliva not only helps in digestion of food, maintain oral hygiene but also helps in regulating water balance of body. Excessive production of saliva or sialorrhea is a medical and psychosocial problem. It may be due to various dysfunction like sensory, neuromuscular, hypersecretion or even anatomic (motor). Mentally retarded children and those with cerebral palsy are more prone to it. This may lead to social embarrassment, low self-esteem and social alienation in the affected person. Proper assessment and diagnosis is critical in finalizing the treatment plan. A careful diagnosis includes Physical examination, taking family history, observing the neurological co-ordination, searching for evidences of dental problem, any factor contributing to nasal obstruction, observing the severity of drooling. This review article outlines the physiology, etiology, psychosocial effect, evaluation and treatment strategies of sialorrhea.

KEY WORDS: Saliva, sialorrhea, drooling. I. INTRODUCTION Saliva is a combination of secretions from major and minor salivary glands, which comprises of 99% of water and 1% of organic and inorganic substances. Saliva plays a number of roles viz, lubrication for chewing, swallowing of food bolus, transport and breakdown of food by enzymatic reactions, buffering effect, acts as mucosal barrier, has antimicrobial properties and aids in digestive functions[1] Saliva possess an antioxidant property and significant correlation of the total antioxidant capacity is reported between saliva and serum of the patients in previous studies.[2,3] Salivation is a continuous physiologic process for which taste sensation as well as chewing process play initiative role.[4]. Salivary glands are innervated by the nerves of the autonomic nervous system (parasympathetic and sympathetic). A high-flow, low protein saliva is generated due to parasympathetic nerve impulses, whereas a low-flow, high-protein saliva [4] is generated due to sympathetic nerve impulse. Excessive production of saliva known as hypersalivation is also termed as sialorrhea. Sialorrhea also referred as drooling of saliva is caused owing to limitations of a person’s ability to control and swallow oral secretions. It may be due to various dysfunction like sensory, neuromuscular, hypersecretion or even anatomic (motor). Excessive saliva gets collected in mouth and even beyond the lip margin [5]. In infants of 15-18 months of age, this condition is considered normal however in a child of age more than 4 years it is considered pathologic. Drooling is an involuntary process characterized by flow of saliva from the corners of mouth [6]. Moreover, as indicated by Lespargot et al. droolingis in relation with either one or a combination of more than one abnormality listed below:

 Inability to close the lips while swallowing.  Minimum suction pressure.  Incoordination between the suction and swallowing phase [7,8]. When there is excess of drooling it is considered as anterior drooling. Excess discharge of saliva can cause skin irritation. In oral cavity, it may result in oral and perioral infections, poor oral hygiene leading to halitosis, and tooth decay.[7] Another type of drooling is posterior drooling. In posterior drooling, the saliva is inhaled which causes frequent incidences of pneumonia [9], recurrent antibiotic courses for respiratory reasons, signs of chronic inflammatory lung disease.

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ETIOLOGY OF SIALORRHEA

The primary etiology of sialorrhea is the extreme release of saliva or incapability to hold saliva in the mouth. It is mainly a result of lack of neuromuscular control of the tongue, difficulty in deglutination, problem in oral tissues. Proper control and movement of tongue, healthy oral tissues & effective swallowing is required to ensure that saliva flows smoothly from the oral cavity to the oropharynx and afar.[5]. Etiological factors (fig.1) causing sialorrhea are neuromuscular dysfunction (fig.2) , oral pathologies (fig.3), systemic diseases (fig.4), drugs and medication(fig.5), psychiatric disorders, even toxic substances and other factors(fig.6)[10].

Etiology of Sialorrhea

Neurological Oral Systematic Drugs Others

Figure 1 : ETIOLOGY OF SIALORRHEA

•Cerebral palsy •Parkinson’s disease •Amyotrophic lateral sclerosis(ALS) Neurological Disease •Facial paralysis •Psychosis •Down’s syndrome •Myasthenia gravis

Figure 2 : NEUROMUSCULAR DISFUNCTION

•Ulcerations( mucosal, traumatic and herpetic) •erruption of teeth •Oral lichen planus Oral Conditions •Oral pain: Pulpitis, periodontitis •Stomatis. •Head and neck surgical defects(Andy Gump deformity)

Figure 3 : ORAL PATHOLOGIES

•Respiratiry obstruction Systemic Disease •Heavy metal toxicity and poisoning •Overhydration

Figure 4 : SYSTEMIC DISEASES

•Direct cholinergic/muscarinic agonists •Indirect cholinergic Drugs •Antipsychotics •Poisons and toxins

Figure 5 DRUGS AND MEDICATIONS

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 •Child’s emotional status •Head position •Posture •Concentration Other Factors •Malocclusion •Tongue size and control •Ability to feel the lips •Degree of nasal obstruction

Figure 6 : OTHER FACTORS II. ASSESSMENT OF SIALORRHEA

Evaluation of the severity and intensity of sialorrhea assists in preparing a suitable treatment plan for the patient, also to determine the prognosis of the treatment. The first step in assessing the severity of sialorrhea is by taking a proper and detailed history. The child, parents, teachers, nurses are interviewed to formulate a detailed history from the onset of the situation to the present condition [11]. Clinical aspects like cerebral palsy influence the severity of sialorreha, thereby making history taking a difficult part. In such a scenario, everyday actions of the child are carefully observed and recorded. Physical examination, family history, observing the neurological co- ordination, searching for evidences of dental problem, dermatological situations due to excess drooling or any factor contributing to nasal obstruction, are also noted [12]

Medical assessment to evaluate the severity of sialorrhea depend on

 Medications that are taken at present by the child  History of aspiration,  Respiratory status and lower airway investigation  Neurologic valuation  Gastroesophageal reflux disease (GERD) Social evaluation

 Evaluating child’s self-management skills  Evaluating child’s behavior and interaction with other people  Assessing the behavior and attitude of the parents towards the child  Assessing the degree of confidence of the child Motor/Oromotor evaluation  Head control  Positioning of the child  Mouth closure  Occlusion,  Lip seal  Sensorimotor assessment  Ability to swallow and wipe saliva by self Several objective and subjective tests are created to assess sialorrhea. The objective test techniques consist of

 Radioisotope-scanning,  Salivary flow is measured by collecting it in a collection cup attached to patient’s chin [13],  Direct observation by counting the daily quantity of napkins used to encompass excessive saliva production,  Quantifying the weight of towels, bibs and dental cotton rolls.[12]. Another type of tests are the usage of subjective scales. These tests are helpful to assess the severity and influence of sialorrhea in qualitative and quantitative terms. These scales are termed as drooling frequency scale, drooling severity scale, the drooling rate scale, the drooling impact scales, visual analog scales. Assessment of drooling severity scale (Table1) and drooling frequency scale (Table 2) can be challenging; Ellis and coworkers

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 have demonstrated direct measurement. Rating scales are quite subjective, but useful. To assess the severity and intensity of drooling in a patient and to monitor sialorrhea in the course of long-term treatment, rating scales are often used. Rating scales are quite subjective but are widely used to show the influence of treatment on quality of life.[14] Table 1: Drooling severity scale [15]

Score Drooling severity 1 Dry, no drooling 2 Mild drooling, wetness on lips only 3 Moderate drooling, wetness on lips and chin 4 Severe drooling, drools make the clothes moist 5 Profuse drooling, things become wet

Table 2: Drooling frequency scale: [13, 15]

Score Frequency 1 Certainly, no drool 2 Drooling occurs rarely 3 Frequent drooling 4 Constant drooling

Summation of the two subjective scale scores (Drooling severity scale and Drooling frequency scale) gives the drooling score. It ranges from a minimum of 2 to a maximum of 9. Teacher Drooling Scale (Table 3), UPDRS part II (for patients with drooling in PD) or Visual Analogue Scale (range 0 – 4) [15] are the other commonly used scales for assessment of salivation.

Table 3: Teacher Drooling Scale [14]

GRADE SYMPTOMS 1 Absence of drooling 2 Irregular drooling, only in trivial quantity 3 Occasional drooling, discontinuous entire day 4 Frequently drools but not plentiful 5 Constantly drools, continuously wet

Objective methods to assess sialorrhea:

 Drooling Quotient (DQ)  Sochaniwskyj’s technique  Thomas-Stonnel and Greenberg scale The satisfaction and effectiveness of the treatment is assessed, by the evaluation of the prognosis of the treatment and its influence on families, folks, caregivers, and patient himself. Subjective scales are advantageous and suitable approaches to measure alterations in sialorrhea. Although, more precise evaluation to detect the reduction in sialorreha or drooling is carried out by objective methods. Objective methods are more sensitive and precise than the subjective methods in assessing the prognosis of the treatment.[12]

III. PSYCHOSOCIAL EFFECTS ON CHILDREN

Quality of life of a child [16] is adversely affected by sialorrhea and has a negative effect which may vary from mild and inconvenient symptoms to severe problems. The child might encounter various problems viz-impaired speech, difficulty in swallowing, serious feeding difficulty, maceration with secondary infection, bad smell from mouth and dehydration. The child may be required to wear a bib to contain the salivary discharge. The clothes and/or bibs become wet frequently and need to be changed frequently [17]. There will be difficulty in studies and interaction with fellow students and they may not share the books, computer keyboards &toys [18]. This may lead to social embarrassment [17] for the child, low self-esteem and he may feel alienated from the society and may not actively participate in social functions. Even the family members or the caretakers [19] may not sympathize with the medical condition of the child and may ignore him. In extreme scenarios, the child may fall into depression and it may worsen further.

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 IV. TREATMENT OF SIALORRHEA

Treatment of sialorrhea is achieved with an efficient and multidisciplinary team approach. Even after effective treatment strategies to lessen the saliva production, management of sialorrhea remains to be a task. When formulating a treatment protocol for patients with sialorrhea, an effort is ought to maintain the normal functions of saliva as far as possible. The areas of concern for children having sialorrhea with any neurological condition are excess of drooling, lack of coordination to carry out neuromuscular functions like swallowing, failure to achieve a proper lip seal, improper speech and many more problems.[12] After a thorough assessment of complete history, physical examination, the influence of drooling on the mental health, life’s quality, and observation of attitude as well as support of family members towards the patient, a treatment plan is formulated.[20] The primary care physicians make a treatment plan based on the medical, physiological, psychological, social factors affecting the patient. They devise a stepwise treatment plan which varies from least invasive treatment options to the most invasive treatment therapies [21]. The distinctive treatment strategies (fig.7) differ and may be a combination of conservative, pharmacological and invasive treatment approaches.

Treatment Strategies

Conservative Pharmocological Invasive Approach Approach Approach

Alteration in diet or Anticholinergic Radiation therapy habits medications

By teaching Surgical methods oromotor exercises Botulinum Toxins

By the use of Intra oral devices

Positioning techniques

Speech therapies

Figure 7 : TREATMENT STRATEGIES

The objective of treatment of drooling is to lessen the extreme flow of saliva, while sustaining a moist and healthy oral environment. The primary treatment modality for children is physical therapy and counselling sessions along with the conservative treatment approach. Speech therapists [20] work with patients and educate them on swallowing mechanics, improve their swallowing mechanism and maintain their postures with devices such as headback wheelchair. Oro- facial therapy as well as oral motor therapy are employed to improve the oral

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 muscular function like suction, swallowing, lip closure, tongue retraction. The psychologist educates the patients on behavioral skills [22], counsels them and helps them gain self-confidence. [7,14]

ANTICHOLINERGIC MEDICATIONS

Anticholinergic drugs act by blocking the parasympathetic innervation of salivary glands. The best-known drug used in sialorrhea is Glycopurrolate. It has drying properties as well as shows limited central nervous system activity. Blockade of M4- Cholinergic receptors by pirenzepine is another mechanism of anticholinergic preparations used in the management of drooling. As stated in “A comprehensive systematic review of the use of anticholinergics in children”, Benztropine, administered 3-3.8mg per day, can be efficient.[12]

BOTULINUM TOXINS

Botulinum toxins develop new aspects in the management of sialorrhea. Botulinum toxin injection does not have any impact on the composition of enzymes and proteins but reduces the amount of saliva. This drug administers its anticholinergic property by blocking autonomic ganglia and neuromuscular junction. Type A and Type B are the two commercially available botulinum toxins[12,15]. The objective of administering botox in the salivary glands of patients with certain neurological ailment is to lessen sialorrhea initiated by means of loss of facial muscles and oral muscle control, that play role during deglutination, speech and other movements of facial muscles[23].One of the option is to administer BTXA injections in the salivary glands. 5-50 units of BTXA is administered in each salivary gland and this method has proven to be quite effective.[15]

RADIATION THERAPY

Elderly patients are generally unable to undergo prolonged medical therapy and even surgery as an option is sometimes ruled out. In such patients, Radiation therapy is one of the preferred choices[20]. The aim of exposing the patient with ionizing radiation is to decrease the salivary secretions. Radiotherapy is initially avoided because of the risk of malignancies, osteoradionecrosis and delayed growth in children. This treatment might be beneficial in certain neurological conditions.

SURGICAL THERAPY

Surgical therapy in treatment of Sialorrhea is the last management strategy suggested in cases, where conservative treatment options were not successful. Surgery assures a larger and long-lasting effect. Surgical options comprise surgery of salivary glands and ducts. The utmost decisive management is removal of salivary glands, or rerouting of the ducts of major salivary glands. The standard operative technique is a combination of ligation and rerouting of parotid duct with submandibular gland duct. In a few months after the surgery, the fibers regenerate and normal salivary function is restored.[15]

V. CONCLUSION

Though sialorrhea is one of the challenging condition to manage, present article describes various assessment & management options. The choice of a treatment depends on severity and investigation results. Treatment of sialorrhea is primarily achieved by a multi-disciplinary team approach and as a single or combination of non- surgical therapy, pharmacological approach and invasive surgical approach. In the end, we want to highlight that sialorrhea results in various challenging physical and psychosocial obstacles, which has a marked undesirable influence on patient and his caregiver’s life quality. Formulating the treatment plan with an excellent prognosis by keeping in mind the primary cause of sialorrhea and its substantial effect on the patient is the first step towards improving the quality of the patient.

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