108 CHAPTER 5 INTRODUCTION Drooling, a prevalent problem (44%) in children with non-progressive neurodevelopmental disabilities, including cerebral palsy (CP),1 has a substantial impact on the well-being and daily life of children and caregivers. Frequent wiping and changing of bibs and clothes are required whilst saliva damages peri-oral skin, clothes, communication aids, furniture and floors. Beyond the physical implications of sialorrhea, drooling may be a main source of social and emotional distress and may have a negative impact on self-esteem and participation in society, school activities and family life.2-4 Additionally, drooling may lead to avoidance by others, social isolation and an underestimation of mental capacities even though cognitive functions are not necessarily impaired.2 Caregivers have expressed concern about the risk of embarrassment, social isolation and stigmatization.3 When conservative treatment (oral motor therapy or behavioral therapy) are ineffective, one could consider anticholinergics, botulinum neurotoxin type A (BoNT-A), or surgery. In our view, anticholinergics are currently only considered in case of lack of effect or contraindications to surgery or BoNT-A. While there is still a chance for patients to ‘outgrow’ drooling, BoNT-A could be considered from the age of 4 years. Our saliva control team primarily focusses on the submandibular glands for interventional therapy, as the submandibular glands are responsible for 70% of the total saliva production in the unstimulated state. Combined injections (parotid and submandibular) are only considered when there was no or inadequate response of submandibular BoNT-A to prevent patients are overtreated when initially combining injections, and to limit related morbidity.5,6 Submandibular duct ligation (2-DL) was recently described as a short and simple day treatment procedure, offering an alternative to BoNT-A and more invasive surgery like submandibular duct relocation (SMDR) and submandibular gland extirpation (SMGE).5,7 A recent RCT from our research group showed almost 90% treatment success in drooling reduction 8 weeks after 2-DL compared to a treatment success of 54% 8 weeks after submandibular BoNT-A which is only slightly lower than
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