66 CHAPTER 3 INTRODUCTION Drooling is the unintentional loss of saliva from the mouth; it is considered pathological above the age of 4 years. In many children and adolescents with cerebral palsy (CP) or any other non-progressive developmental disorder, drooling is a major burden. Approximately 40% of children with CP experience drooling, which has high physical and social-emotional morbidity and a major impact on their daily lives.1,2 The treatment of drooling is a clinical challenge since not all treatment options are well suited to every child in this vulnerable patient population. Submandibular glands are responsible for 70% of total saliva production in the unstimulated state. Therefore, at our institution, submandibular glands are the primary aim for interventional therapy. Botulinum neurotoxin A (BoNT-A) injections into the submandibular glands are frequently used to treat drooling when more conservative treatments such as oral or behavioural therapy and anticholinergic medications have failed to achieve satisfactory results.3 BoNT-A has been shown to be effective4,5 and is minimally invasive. Adverse events are usually minor and include mainly changes in oral-motor function.6 However, the effects of BoNT-A treatment are by nature temporary, lasting for only several months; thus, repeated injections under general anaesthesia are needed to maintain the effects of BoNT-A. This produces an increased burden with the risks of repetitive anaesthesia and potential adverse effects, which ultimately results in patients and carers opting for longer-lasting treatment modalities. During the past decades, several surgical procedures have been suggested to achieve longer-lasting results. Submandibular duct relocation (SMDR), where the submandibular ducts are relocated from the anterior oral cavity to the base of the tongue, is currently one of the most effective surgical procedures.7–12 The main downside of SMDR is perioperative morbidity, which requires hospitalization for multiple days, including a 1-night admission to the intensive care unit for assisted breathing due to the risk of airway obstruction as a result of postoperative swelling of the mouth floor. Another potential, although smaller risk, is damage to the lingual
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