194 GENERAL DISCUSSION o Progressive neurological disease o Affected pharyngeal phase of swallowing o Signs of aspiration o Posterior drooling • Patients with combined anterior and posterior drooling It remains unclear what surgery to advocate in case of recurrence after 2-DL. We used to suggest SMGE for recurrence of drooling after 2-DL, but this thesis shows the insufficient benefit of the latter. Future research should investigate this dilemma. Perhaps additional uni- or bilateral parotid duct ligation (in combination with SMGE) would be more successful. Ultimately, even though drooling is not caused by hypersalivation, surgical treatment for drooling aims to reduce or replace salivary flow. In our opinion, it is essential to inform patients, parents, and health professionals about the balance between oral hygiene (sufficient saliva) and salivary flow reduction. Therefore, it is impossible to obtain a perfect result after surgery, and it is not realistic to expect complete control of anterior drooling. We feel expectation management is a critical factor for treatment success. Future perspectives One of the main findings of this thesis is that, although 2-DL is an effective and short procedure that is less invasive than SMGE and SMDR, there is a certain degree of recurrence. Presumably, there is recurrence due to alternative salivary pathways. Future studies should evaluate techniques to prevent alternative salivary pathway formation after 2-DL. Possible procedures could include: - 2-DL proximal to the duct of Bartholin (‘2-DL extended’) - Bilateral sublingual gland extirpation combined with 2-DL - Intra-submandibular duct sclerosing therapy combined with 2-DL to prevent alternative salivary pathways. The following chapter describes the study protocol for Ethanol submandibular duct ligation.
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