225 ligation in 3 patients. One patient underwent tertiary surgery (parotid duct ligation after re-intervention by submandibular gland excision). Only three patients were successful after re-intervention, defined as a 50% reduction of VAS and/or DQ from baseline to 32 weeks. No difference was found between the technique of reintervention (parotid duct ligation or submandibular gland extirpation). There were significantly more cases with severe dental malocclusion (50% vs. 21%, P-value = 0.047) and very severe speech disorders (80% vs. 42%, P-value = 0.042) in the current cohort when compared to the reference cohort. Recurrence of drooling surgery is most likely not only caused by alternative salivary pathways or surgical failure of the primary intervention because re-intervention (submandibular gland excision) did not lead to treatment success. Dysarthria and dental malocclusion might negatively influence treatment outcomes, but future research is needed to confirm its predictive value. Furthermore, based on the findings in this study, it is not possible to exclude compensatory hypersalivation after submandibular duct surgery. Discussion and conclusion Most patients respond well to 2-DL by relieving the impact of drooling on daily life and care, material damage, and social interaction. There is nevertheless a certain degree of treatment failure and recurrence after 2-DL. Treatment failure and recurrence after 2-DL is presumably multifactorial wherein a component by alternative salivary pathway) is probable. The effect of 2-DL seems inferior to other surgical procedures like SMDR and SMGE. However, 2-DL is a short procedure that is performed in an outpatient setting with comparably limited risk for serious adverse events. This thesis moreoverconfirmsthatsubmandibularBoNT-Aiseffectiveforthetreatment of anterior drooling, with significant relief of impact of drooling on daily life and care, andimprovement insocial interactionandself-esteemwhereinthecostsarerelatively low, and there is only a limited risk for adverse events and postoperative complaints.
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