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SIALORRHEA: CHALLENGES and MANAGEMENT Mahima Sehgal1, Dr

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SIALORRHEA: CHALLENGES and MANAGEMENT Mahima Sehgal1, Dr 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. 5655 ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 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 5656 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 5657 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
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