180 CHAPTER 8 Given the number of non-responders after secondary drooling surgery there are indications that, most likely due to all the influencing clinical variables, prediction of therapy outcome is very difficult. As displayed in Table 1 and 2, our patients suffered from; severe neurological impairment, epilepsy, gastroesophageal reflux disease (GERD), poor posture, suboptimal dental occlusion, incomplete lip seal and poor oro-motor control. These factors are inevitably related to anterior drooling and in addition, we found that the patients in this study suffered from dysphagia and significantly more dental malocclusion and severe speech disorders (classified as no speech, anarthria or very severe dysarthria) which potentially negatively influences therapy outcomes and contributes to refractory anterior drooling despite a thorough reduction in salivary flow.6,20 This is in line with Franklin et al29 who already described in 1996 the relevance of dental occlusion in relation to drooling. In addition, Reid et al6 found a relation between limited speech and drooling, and concluded that poor oromotor function was associated with drooling. Cerebral palsy associated with reduced oral muscle tone and preferential mouth breathing could be the cause of the identified dental malocclusion and dysarthria. Previous research has focused on trying to identify influencing clinical factors on therapy outcome after botulinumneurotoxin type A injections and SMDR. Adequate head posture and age >12 years predicted treatment success after SMDR, but unfortunately no predictors to treatment success after BoNT-A were found.20 Also hypersalivation has been hypothesized as a reason for therapy failure, but has shown to be inconsequential in children with CP.4 Despite the fact that our study is retrospective and based on limited data, we provide new insights about the efficacy of surgical re-intervention for drooling. We used prospectively collected objective and subjective outcome measures with a decent follow-up protocol. Martin et al 22 report use of technetium scanning to identify the fate of submandibular duct diversion and ligation, respectively. Nevertheless, we believe in our patient population technetium scanning is unethical as a routine ‘research’ procedure.
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