Sialorrhea.pptx

over view about sialorrhea ,its effect on patient and recent treatments .
it was presented in pediatric conferance in Al-Azhar university by doctor Ahmed Abdelhadi

1. " قَالُواْ سُبْحَٰنَكَ لَا عِلْمَ لَنَآ إِلَّا مَا عَلَّمْتَنَآ ۖ إِنَّكَ أَنتَ ٱلْعَلِيمُ ٱلْحَكِيمُ " صدق الله العظيم 1

2. Ahmed Abdelhadi 4 th Grade Medical Student SIALORRHEA In children 2

3. Contents 1- Def of Sialorrhea 2- Problems of Sialorrhea 3- Pathophysiology of Sialorrhea 4- Causes of Sialorrhea 5- Diagnosis of Sialorrhea 6- Management of Sialorrhea #

4. Def : Sialorrhea (drooling) is the unintentional loss of saliva from the mouth.  OVERVIEW The term drooling commonly refers to anterior drooling and should be distinguished from posterior drooling . Drooling is a significant disability for a large number of pediatric and adult patients specially with  cerebral palsy

5. All Children Have Drooling ! Drooling is a normal phenomenon in children prior to the development of oral neuromuscular control at age 18-24 months. However, drooling after age 4 years is uniformly considered abnormal. FACT

6. Functional Social & psychological Clinical What are the problems of SIALORRHEA ? 6 Affect on the quality of life. May limit the family's ability to be active and out of the home. Teaching materials and communicative devices may become wet and damaged. Social embarrassment may make it difficult for patients who drool to interact with their peers and can lead to isolation. R epeated perioral skin breakdown and infections. In severe cases of drooling, dehydration may even become a problem.

7. causes congested breathing, coughing, gagging, vomiting, and at times, aspiration into the trachea that results in recurrent  pneumonia. Posterior Sialorrhea

8. Physiology of Salivary Glands The salivary glands secrete an average of 1-1.5 L of saliva per day. The 3 groups of major paired salivary glands , the submandibular , sublingual , and parotid glands , along with the minor salivary glands located throughout the surface of the palate, tongue, and oral mucosa, secrete saliva.

9. The submandibular gland produces 70% of resting secretions. The 20% from the parotid glands is a result of external stimuli such as food. The remaining 10% of saliva secreted is from the sublingual and remaining minor salivary glands.

10. The secretory control of the salivary glands is mostly parasympathetic . Innervation of the parotid gland is from the salivary nucleus via the glossopharyngeal nerve , the tympanic plexus in the middle ear, the otic ganglion , and the auriculotemporal nerve . The submandibular and sublingual glands receive fibers carried by the facial nerve and chorda tympani , which originate in the superior salivatory nucleus.

11. PATHOPHYSIOLOGY Primary : Sialorrhea occur as a result of hypersecretion of the salivary gland ( less common ). Secondary : Sialorrhea occur due to impaired neuromuscular control with dysfunctional voluntary oral motor activity that leads to an overflow of saliva from the mouth ( more common ) .  

12. 13 1 Primary Sialorrhea Hypersecretion is a rare cause of drooling. Most often, this occurs as an adverse effect of medications such as some tranquilizers , anticonvulsants , and anticholinesterases that increase activity at the muscarinic receptors of the secretomotor pathway and result in hypersecretion.

13. Secondary Sialorrhea Any impairment of the oral phase of deglutition secondary to neuromuscular disorders , trauma, surgical resection, or facial nerve paralysis  can result in spillage of saliva from the oral cavity. Most patients who drool have impaired oral neuromuscular control due to cerebral palsy or severe mental retardation. 2 14

14. 15 Other clinical factors that could contribute to drooling and spillage of oral contents should be explored while taking the patient's history. N.B.

15. P oor head control 1 16

16. 2 E nlarged tongue 17

17. Dental caries 3 18

18. Gingivitis 4 19

19. GERD 5 20

20. How To Diagnose ? 21

21. 22 Diagnosis HISTORY Make an assessment of the severity and frequency of drooling , and inquire about the effect on the quality of life for the patient & family . I dentify factors contributing to drooling . Physical examination Perform a thorough head and neck examination . Give special consideration to those anatomic factors that could contribute to or exacerbate drooling .

22. 23 Head position and control Condition of perioral skin Tonsil and adenoid size Dentition: Caries may be noted. Gingival tissues Presence of mouth breathing Nasal obstruction ( adenoid ) Neurologic examination (cranial nerves) Physical examination

23. Patients with cerebral palsy are often affected by varying degrees of physical disability, including lack of muscle tone affecting head position and oral dysfunction, which causes the initiation of swallowing to be uncoordinated and inefficient. Exercises are used to attempt to normalize muscle tone , stabilize body and head position, promote jaw stability and lip closure, decrease tongue thrust , increase oral sensation , and promote swallowing . *Treat the cause if exist Oral motor training 24 Medical Therapy

24. Oral motor training 25 Medical Therapy Oral motor training is time consuming. The therapy requires a minimal level of cognitive function and motivation on the part of the patient and caregiver. Very few data are available to confirm the effectiveness of these therapies. However, because of the noninvasive nature and the varied response of individual patients, all patients capable of this therapy should undergo at least a 6-month trial of oral motor training.

25. Verbal and auditory cues are used to attempt to increase the frequency and efficiency of swallowing. Several methods, including reward , overcorrection , and punishment , are used by caregivers to initiate swallowing. External devices that deliver timed auditory cues to swallow are also used. Medical Therapy Behavioral therapy 26

26. Anticholinergics The use of anticholinergics to inhibit activation at muscarinic receptors . Adverse effects include irritability restlessness sedation constipation Photophobia urinary retention Pharmacologic therapy Medical Therapy 27

27. Medical Therapy Anticholinergic s e.g. Transdermal scopolamine has been used with success for short periods. No data illustrate its efficacy over longer periods. Glycopyrrolate (injection ) was also shown to decrease drooling in 95% of patients.   However, 30% of patients discontinue treatment because of adverse medication effects Pharmacologic therapy 28

28. SURGICAL TTT In most cases, surgical intervention should be instituted following the failure of at least 6 months of more conservative therapy. Surgery is best delayed until the patient is aged 6 years or older in order to allow time for complete maturation of oral motor function and coordination. 29

29. In most cases, surgical intervention should be instituted following the failure of at least 6 months of more conservative therapy. . P ersistent drooling following at least 6 months of conservative therapy. M oderate to profuse drooling in a patient whose cognitive function precludes participation with conservative oral and physical therapy. Indications 30

30. Botulinum toxin 

31. Botulinum toxin  Botulinum toxin is an exotoxin produced by the bacterium  Clostridium botulinum , a gram-positive, anaerobic bacillus. Botulinum toxin type A is one of 8 distinct known neurotoxins, each with its own immunologic specificity.     It leads to partial or complete muscle paralysis by inhibiting acetylcholine release at the neuromuscular synaptic end plate.

32. Botulinum toxin  This toxin also blocks the release of acetylcholine at the cholinergic synapses of the autonomic nervous system; thus, this toxin can block cholinergic parasympathetic secretomotor fibers of the salivary gland. Botulinum toxin can be injected into the parotid gland, but better results are obtained when it is injected into both the parotid and submandibular glands guided by US .

33. 35 TAKEAWAY Sialorrhea is a common problem among CP & severe mental impaired patients . Although they are not able to help them selves ( Handicap ) , but they are humans have feelings exactly like us so our mission is to increase awareness about their needs & to protect them from bullying . If we can’t treat them , at least we should try to improve their quality of life

34. 36 صدق الله العظيم " وَمَا أُوتِيتُم مِّنَ الْعِلْمِ إِلَّا قَلِيلًا "

35. Thank U Ahmed Abdelhadi Ahmed