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

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

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

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

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

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

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

INTRODUCTION

The prophylactic coadministration of anticholinergics during dissociative sedation has been considered necessary to mitigate ketamine-associated hypersalivation. Given recent conflicting conclusions regarding adjunctive atropine, we compared the incidence of hypersalivation, degree of secretion, and related side effects with atropine or placebo as an adjunct to intravenous (IV) ketamine sedation for children.

METHODS

This controlled trial randomized children, 1 to 10 years old, requiring ketamine sedation in a tertiary emergency department to receive 0.01 mg/kg of atropine or placebo, along with IV ketamine (2 mg/kg). A nurse rated preprocedure and postprocedure salivation on a 100-mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation.

RESULTS

During 27 months, 140 patients were enrolled. Baseline characteristics did not differ between the 2 groups (P > .05). Secretion was significantly less in the atropine vs placebo group (mean visual analog scale score ± SD, 21.2 ± 13.1 [preprocedure] to 16.5 ± 9.9 [postprocedure] vs 22.4 ± 13.5 [preprocedure] to 27.0 ± 15.9 [postprocedure], respectively; P < .05). Visual analog scale scores greater than 50 were assigned to 7 (9.7%) of 72 and 1 (1.5%) of 68 patients in the placebo and atropine groups, respectively; these patients needed only medical procedures such as suction or airway repositioning. Heart rate was significantly higher in the atropine group compared with the placebo group (P < .05). There were no significant differences between the groups in terms of other adverse events.

CONCLUSION

Atropine as an adjunct to IV ketamine sedation in children significantly reduced hypersalivation, without providing a clinical benefit.

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

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

Use of botulinum toxin in dentistry

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

Post-surgical role of botulinum toxin-A injection in patients with head and neck cancer: personal experience

Personal experience is discussed in the use of botulinum neurotoxin injections into both parotids, performed in order to transiently reduce salivation in patients undergoing major ablative and ablative-reconstructive oncologic surgery for head and neck tumours. Overall, 8 adult patients (2 female, 6 male) have been treated. Six cases were affected by pharyngocutaneous fistulas, one by severe sialorrhoea and one recurrent sialocele. After the injection, patients were regularly observed at follow-up and asked to give their subjective assessment of salivary flow. Investigations concerning possible complaints, including side-effects, as well as complete examination of the head and neck area were performed. Follow-up periods ranged from 12 to 24 weeks (mean 20 weeks). Following botulinum neurotoxin injection, the fistula was dry after a mean period of 4.5 days (min 3 days, max 8 days) and was closed 6.6 days (min 5 days, max 8 days) later. The patient affected by severe hypersalivation reported subjective improvement in sialorrhoea 4 days post-treatment. The patient affected by recurrent sialocele, required only one aspiration of fluid two days after the treatment, after which there were no further problems. Post-operative saliva-related complications significantly increase patient morbidity and hospital stay after major tumour surgery. The easy, safe and effective treatment with botulinum neurotoxin injection, observed in our experience, suggest its significant role as a useful option in the post-operative saliva-related complications.

Prosthodontic management of angular cheilitis and persistent drooling: a case report

This article describes a case of persistent saliva drooling, and the accompanying chronic angular cheilitis, that is not uncommon in the elderly patient population. A drug therapy and the temporomandibular joint aspect of vertical dimension of occlusion during prosthodontic evaluation and construction are presented. Also described is a method to incorporate a canula into the denture prosthesis to channel the saliva toward the oropharyngeal area for geriatric and handicapped patients who suffer from chronic drooling and angular cheilitis.

Does the addition of sublingual gland excision to submandibular duct relocation give better overall results in drooling control?

Submandibular duct relocation plus or minus excision of the sublingual glands are relatively simple procedures with low morbidity. Between 1981 and 2005, 71 submandibular duct relocation and 29 submandibular duct relocation plus excision of the sublingual glands procedures were conducted.

OBJECTIVES

To compare both procedures including operative time, length of hospital stay, postoperative complications, drooling scores and parental satisfaction.

STUDY DESIGN

Prospective study.

SETTING

Paediatric tertiary referral centre.

PARTICIPANTS

Patients referred with excessive drooling after failure of conservative methods.

EXCLUSION CRITERIA

patients with recurrent aspiration pneumonias or dental caries. Two patients were lost to follow up and excluded from the study.

RESULTS

Operative time and length of hospital stay were increased in the submandibular duct relocation plus sublingual gland excision group. Drooling scores and parental satisfaction results were excellent, 93% of parents in the submandibular duct relocation group and 89% of parents in the duct relocation plus sublingual glands excision were satisfied and would recommend the procedure. There was no statistical difference (P = 0.643) in drooling scores between the two procedures. Postoperative morbidity was higher with the addition of sublingual gland excision, with postoperative haemorrhage occurring in 13.7% and 36% of parents expressing concern over postoperative pain, compared with 3% postoperative haemorrhage rate with submandibular duct relocation and only 12% of parents expressing the same concerns.

CONCLUSION

We conclude that both procedures are effective in drooling control, but the addition of sublingual gland excision increases morbidity and we are no longer excising these glands with submandibular duct relocation.

Removal of the laryngeal tube in children: anaesthetized compared with awake

BACKGROUND

Laryngeal tube (LT) is a useful airway device in children, but there is no objective evidence that removal of LT in awake state is better than in anaesthetized state. So, we compared the incidence of respiratory adverse events after the removal of LT, either under anaesthesia or on awakening.

METHODS

Seventy healthy children between 1 and 12 yr of age were enrolled in this study. Anaesthesia was induced and maintained with sevoflurane. After induction of anaesthesia, patients were randomized into two groups: removal of LT in anaesthetized state (Group A: 2% sevoflurane) and in awake state (Group B). During and within 1 min of the removal of LT, airway complications such as upper airway obstruction, cough, vomiting, teeth clenching, hypersalivation, desaturation <90%, and laryngospasm were recorded.

RESULTS

Cough (37.1 vs 2.9%), hypersalivation (28.6 vs 5.7%), desaturation (20 vs 0%), and LT dislocation during emergence relating to the patient's movement (26.5 vs 0%) occurred more frequently in Group B (P < 0.05). Upper airway obstruction occurred more frequently (68.6 vs 31.4%) in Group A, and it was easily resolved by chin or jaw lifting.

CONCLUSION

LT removal in anaesthetized state reduced cough, hypersalivation, and prevented tube displacement and hypoxia. Upper airway obstruction in the anaesthetized state should be predicted and managed with chin or jaw lifting.

Drooling

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.

Respiratory distress secondary to esophageal foreign body: a case report

The ingestion or aspiration of a foreign body is a common, but preventable occurrence in childhood. Primary healthcare personnel should alert parents to the risk of swallowing a foreign object, the signs and the need for immediate medical attention. It should be emphasized that protecting children from access to objects that can be swallowed or aspirated is the best preventive measure. A case of an eight year old child, who had swallowed a marble ball is presented and the symptoms and intervention discussed. Medical staff should be aware of the symptomatic variation in ingested foreign body presentation and the importance of rapid diagnosis and management.

[The symptomatic treatment of amyotrophic lateral sclerosis]

Patients with amyotrophic lateral sclerosis (ALS) have symptoms of progressive muscle weakness, of disturbed speech and swallowing, and in the terminal phase those of respiratory weakness. Treatment options, in particular those for excessive weight loss and respiratory weakness, should be introduced to the patients and their families when the patient is emotionally capable and before dysarthria severely hampers communication. Special equipment for keeping the patient as mobile as possible should be made available much earlier than in the case of other diseases of the muscles as in ALS progression is much faster. Cramps, pathological crying or laughter, spasms, and spasticity can all be treated by medication. When speech can no longer be understood, adaptive strategies such as sign language, mime, posture and communication apparatus varying from a note pad to advanced computer systems can be used. Sialorrhoea, caused by difficulty swallowing with its accompanying danger of aspiration can be halted by the use of medication, by radiotherapy and by the injection into the salivary glands of botulin A toxin. Weight loss, also a result of dysphagia, can be avoided by eating frequent small meals or if necessary performing a percutaneous endoscopic or radiological gastroscopy. Excess mucus in the respiratory tract can be treated with anticholinergics. Difficulty in coughing up thick and sticky mucus cannot always be adequately helped. Respiratory weakness is treatable by external respiratory supportive therapy using a nasal mask, as well as invasive respiratory support via a trachcostoma and by treating the symptoms of respiratory weakness. The latter form of treatment is palliative and forms part of terminal care. During the terminal phase restlessness, anxiety, pain, and dyspnoea require the most attention. Treatment requires careful multidisciplinary cooperation.

The use of a removable appliance to improve oral continence in an elderly dentate patient

Challenges in the treatment of our older dentate patients are arising more frequently, and novel solutions may be required to overcome them. This case report describes the treatment given to an elderly dentate female patient, whose lax peri-oral musculature was preventing a satisfactory oral seal from being achieved. This resulted in constant "drooling" and much social disability in an otherwise fit and gregarious lady. A simple removable appliance was provided to increase support to the tissues at the angles of the mouth. An immediate relief of the salivary leakage was achieved and maintained. Simple solutions may be available to problems which may cause great distress to our patients reducing the quality of their lives. This solution to the problem of peri-oral leakage, of a normal volume of saliva, may be useful for many other patients with similar problems, following loss of peri-oral muscle tone with age.

Drooling in Parkinson's disease: a novel speech and language therapy intervention

Drooling and difficulty swallowing saliva are commonly reported in people with Parkinson's disease (PD). Drooling in PD is the result of swallowing difficulties rather than excessive saliva production. Currently, there is little research into the effectiveness of treatments to reduce drooling. The aims of the study were to develop objective measures of saliva volume and drooling for PD and to assess the efficacy of two therapeutic strategies to control drooling, i.e. specific speech and language therapy (SLT) including a portable metronome brooch to cue swallowing and injections of botulinum toxin into both parotid glands to reduce the amount of saliva produced. This paper will describe the assessments used, including the measurement of saliva, swallowing and drooling. The main focus will be the strategies used in the SLT intervention. The preliminary results are presented.

Optimizing clozapine treatment

Compliance with conventional antipsychotic medication is often poor, with many patients discontinuing treatment only a few months after commencing therapy. The side effects of treatment, which are not necessarily restricted solely to motor symptoms, are often considered to be responsible for this noncompliance. In contrast to conventional antipsychotics, clozapine is associated with only minimal extrapyramidal symptoms, and in most patients, its use results in significant improvements in compliance. However, clozapine does induce a variety of adverse effects, most of which are of limited duration and either preventable or manageable if a number of simple clinical procedures are followed. Clozapine therapy is associated with a beneficial risk/benefit ratio in the majority of treatment-resistant schizophrenic patients. With careful hematologic control, the risk of agranulocytosis can be minimized. The marked increase in the well-being of patients receiving clozapine should stimulate psychiatrists to broaden its use and not limit it to severely treatment-resistant individuals.

Use of glycopyrrolate and other anticholinergic medications for sialorrhea in children with cerebral palsy

Fifty-four parents/caretakers of children with cerebral palsy were surveyed regarding their use of antisialorrheic medication for excessive drooling. Glycopyrrolate was used by 37 of 41 respondents, with significant improvement in drooling noted in the vast majority (95%) of cases as indicated by a five-point rating scale. Side effects (dry mouth, thick secretions, urinary retention, or flushing) surfaced in almost half (44%) of the patients but necessitated discontinuation of pharmacologic treatment in less than a third. While larger clinical studies are needed, our preliminary data indicate a trial of glycopyrrolate should be considered in children with cerebral palsy where drooling is a significant problem.

[Relationship between cholinergic symptoms caused by distigmine and the activities of serum AChE and BChE]

Distigmine is widely used for the treatment of dysuria, which is caused by various types of psychotropic medications. Distigmine, however, is also known to induce adverse cholinergic effects, such as diarrhea and salivation, with a decreased level of serum cholinesterase. We evaluated the possibility of using serum acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) as specific clinical markers for the adverse cholinergic effects of distigmine. Of the twelve patients treated with distigmine for dysuria caused by psychotropic drugs six patients presented both adverse cholinergic effects and decreased levels of serum AChE and BChE. The other six presented neither of these changes. This study suggests that the values of serum AChE and BChE may be useful markers for the manifestation of adverse cholinergic effects caused by distigmine.

Full-thickness reconstruction of cheek defect involving oral commissure with forearm tendinocutaneous flap

An 82-year-old man underwent full-thickness reconstruction of the cheek for a defect of the oral commissure resulting from a T3N1M0 squamous cell carcinoma. He had previously had both radiotherapy and chemotherapy. A tendinocutaneous flap from the forearm incorporating palmaris longus was used for static reconstruction. The vermilion was then reconstructed with rotation flaps from the contralateral vermilion. Oral function was restored, and he had no problems with drooling or speech.

Observation and measurement of drooling by people with mental retardation

Four brief observational surveys were used to score residents of a state institution for people with mental retardation as drooling/not drooling. An average of 14% of the population was identified as drooling on the occasion of any of the surveys; the accumulated proportion of clients reported as drooling was 28%. In a second study, the drooling of 2 of the clients identified in the first study was sampled within and across days. These clients drooled different amounts both within and between days, which validated their presence and classifications in the first study.

Automatic cueing to reduce drooling: a long-term follow-up with two mentally handicapped persons

A follow-up was carried out on two mentally handicapped persons to check whether automatic cueing remained effective for reducing their drooling. The follow-up data were collected through observation sessions which were spread over a period of 18 months. These sessions together with the posttraining sessions of the original study covered an interval of about 2 years. The results of the follow-up showed that cueing continued to be fairly effective with drooling remaining at relatively low levels.

Ptyalism in pregnant women

Ptyalism affects few pregnant women. Those who suffer from it, however, find it to be a little-known, but major irritant. This article presents several possible etiologies and discusses some vexatious cases of ptyalism. Nursing interventions are also offered. More nursing research must be conducted so that nurses can better understand this problem.

Decreasing drooling with oral motor stimulation in children with multiple disabilities

Many persons with severe and profound disabilities exhibit chronic and excessive drooling, which can have unfavorable effects on their socialization and health. Few treatments to reduce this behavior, however, have been evaluated systematically. In the present investigation, oral motor stimulation was used with 2 children who attended a residential educational facility for students who are blind and who have multiple disabilities. The treatment involved the brushing of the hard palate, the upper and lower gums, the tongue, and the inside of both cheeks at 1-hr intervals during the school day. The efficacy of this approach was demonstrated with a withdrawal experimental design. Because this treatment did not eliminate drooling, vibration was applied to the chin and neck, first in conjunction with the oral motor stimulation and then contingent on the subject's having a dry face. Vibration did not have additional therapeutic effects. The results of this study are discussed in relation to the existing literature on modification of drooling and the difficulty of effecting change in the behavior of persons with severe and profound mental and physical disabilities.

The efficacy of tongue resection in treatment of symptomatic macroglossia in the child

Nine patients with symptomatic macroglossia, 3 with Beckwith-Wiedemann syndrome, 3 with Down's syndrome, and 3 with lymphatic malformation of the tongue, were evaluated for postoperative improvement following partial glossectomy. Symptoms evaluated were speech intelligibility, oral competence at rest, drooling, and normal deglutition. All patients with Down's syndrome and Beckwith-Wiedemann syndrome were improved postoperatively. All patients with Down's syndrome exhibited improved deglutition and reduced drooling. Only 1 patient (33%), however, achieved oral competence. Speech was improved postoperatively in 2 patients (67%) with Down's syndrome. Patients with lymphatic malformation of the tongue did not exhibit consistent long-term improvement postoperatively, suggesting that conservative management of macroglossia in this patient group may be indicated.

Otolaryngologic manifestations of amyotrophic lateral sclerosis

Otolaryngological manifestations were examined in a series of 250 patients diagnosed as having ALS between 1976 and 1986. Surgical intervention was only required in 10 cases due to excessive drooling and aspiration. Five patients had submandibular gland excisions with only limited improvement in respect to drooling. One case having a unilateral tympanic neurectomy had significantly better drooling control. Cricopharyngeal myotomy is helpful when dysphagia is predominantly due to cricopharyngeal spasm. In our series, tympanic neurectomy and chorda tympanectomy provide the better control of drooling for these patients and has the added advantage of being performed under local anesthesia.

A field study of watery mouth: clinical, epidemiological, biochemical, haematological and bacteriological observations

More than 500 cases of watery mouth in newborn lambs were recorded in 11 flocks and a detailed examination was performed in more than 200 cases. The condition occurred predominantly in lambs aged 24 to 48 hours. The incidence in a flock varied from 1 per cent to 24 per cent and the mortality in affected lambs varied from 7 per cent to 83 per cent. A bacteraemia was found in 38 per cent of the affected lambs. There were no consistent abnormalities of clinical biochemistry or haematology. Watery mouth was more common in twins and especially in triplets than in single lambs. In twins the highest incidence of watery mouth was recorded in lambs born to ewes in poor body condition. Antibiotic given orally within 15 minutes of birth greatly reduced the incidence of watery mouth.

The use of overcorrection as a means to control drooling

Excessive drooling in severely retarded students is a common classroom problem. This report presents a short, easy-to-execute correction procedure consisting of cleaning up saliva and pressing a tissue under the lips to decrease drooling. The procedure was used with a severely retarded girl who did not have any severe motor deficiencies. The procedure includes praise for a dry face. The procedure did decrease drooling, and the results were maintained over a 3-month period.

Decreasing drooling through techniques to facilitate mouth closure

A single case ABA experimental design is presented in which techniques to facilitate mouth closure were hypothesized to decrease drooling. The subject was an 11-year-old male with mental retardation and cerebral palsy. Baseline 1 consisted of 10 half-hour sessions of play, followed by 1-hour periods during which the amount of saliva collected on an absorbent bib was measured and recorded. The subsequent treatment phase of 4 weeks was identical to the baseline except that a half-hour period of intervention was substituted for the half-hour of play. Intervention involved providing jaw control with intermittent tapping and jiggling, stroking the upper gum, and giving juice with jaw control. Baseline 2 consisted of 10 sessions identical to baseline 1. Results indicate that the amount of saliva leaving the mouth was a function of the presence or absence of intervention.

Drool control: long-term follow-up

This study reports the long-term follow-up of a group of severely retarded cerebral-palsied children who were conditioned to control their oral drooling by means of an electronic device and shaping and conditioning procedures. Improvement was maintained in these children at nine months, and a larger group of children who were trained by the same method attained significant improvement in drooling both at one week and at three months.

A non-surgical method of reducing drooling in cerebral-palsied children

A programme is described which aimed to reduce drooling volume in groups of cerebral-palsied children. The programme, which lasted one year, required the children to wear chin cups and to attend special 'anti-drooling' classes. The over-all reduction in volume of drooling was 73 per cent.