The burden of sialorrhoea in chronic neurological conditions: current treatment options and the role of incobotulinumtoxinA (Xeomin®)

Abstract

Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson’s disease, motor neuron disease, cerebral palsy, and stroke) and is defined as excessive saliva accumulation leading to unintentional loss of saliva from the mouth. Sialorrhoea increases the overall burden on the patient and their caregivers, the impact of which can be both physical and psychosocial. Treatments for sialorrhoea range from lifestyle and behavioural guidance, to medications, surgery or radiation. Nonpharmacological interventions include advice on posture, swallowing control, cough management, dietary changes, eating and drinking techniques, and behavioural modification; however, these conservative measures may be ineffective for people with progressive neurological conditions. The pharmacological treatment of sialorrhoea is challenging because medications licensed for this purpose are limited, but treatments can include anticholinergic drugs and botulinum toxins. Surgical treatment of sialorrhoea is typically reserved as a last resort for patients. IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US and UK marketing authorization for the symptomatic treatment of chronic sialorrhoea due to neurological disorders in adults. In this review, we discuss and compare the frequency and method of administration, location of treatment delivery, approximate annual costs and main side effects of botulinum toxin and different anticholinergic drugs. Management of patients with chronic neurological conditions requires input from multiple specialist teams and thus a multidisciplinary team (MDT) approach is considered fundamental to ensure that care is consistent and tailored to patients’ needs. To ensure that adult patients with neurological conditions receive the best care and sialorrhoea is well managed, we suggest a potential clinical care pathway for sialorrhoea with a MDT approach, which healthcare professionals could aspire to.

Hypomimia in Parkinson’s disease: an axial sign responsive to levodopa

“…A novel finding of the present study was that PD with hypomimia was associated with more severe axial and orofacial symptoms (speech, swallowing dysfunction, and sialorrhea). Indeed, drooling tested with clinical [25] or instrumental measures [13] has been previously correlated with hypomimia, supporting the view that sialorrhea in PD is mainly caused by an impairment of orofacial and swallowing muscles [26].…”

The Challenges Faced and Lessons Learnt in the Multidisciplinary Management of Medication Refractory Post-Stroke Sialorrhea: A Case Report

“…Hence, most of the literature on the management of sialorrhea deal with PD cases. Although the prevalence of sialorrhea in stroke has not been well-documented, it can lead to medical, psychological, and social complications in stroke patients [4]. The key to the treatment of sialorrhea is multidisciplinary management by a team of specialists that would ideally include a rehabilitation medicine physician, speech therapist, occupational therapist, physiotherapist, otolaryngologist, neurologist, palliative medicine specialist, and radiation specialist [1,3,4].…”

“…The most common cause of post-stroke sialorrhea is related to the neurological impairment that involves either an inability to retain saliva within the mouth secondary to poor orofacial muscular control and/or dysphagia leading to excess pooling of saliva in the anterior oral cavity [2,3]. Sialorrhea can lead to perioral infections, aspiration pneumonia, impaired communication, as well as negative effects on the mental and psychological well-being of both the patient and caregiver [4]. Sialorrhea is often undertreated [5].…”

Oral health effects of botulinum toxin treatment for drooling: a systematic review

“…It usually results in maceration and infections of the peri-oral skin ( 1 - 4 ), dysfunctional eating ( 4 ), disturbed speech ( 1 , 2 , 4 , 5 ), halitosis ( 4 ), aspiration-related pulmonary complications ( 1 - 5 ), and stigmatization or social isolation ( 1 , 2 ). Also, drooling often poses hygienic problems for caregivers because of constant soiling of clothes ( 1 ) and other objects ( 4 ). This prompts the need for effective and safe approaches to manage drooling ( 3 ).…”

“…In general, parasympathetic stimuli increase the output of water and electrolytes, whereas, when sympathetic stimuli dominate, there is an enhancement of protein synthesis and secretion from acinar cells ( 14 , 15 ). Therefore, by interfering with autonomic innervation of salivary glands and, thus, prompting a decrease in salivary flow, BoNT can affect the defense mechanism of saliva and may be associated with changes in the salivary composition ( 16 , 17 ) and increased risk of dental caries development ( 1 , 2 ). However, evidence regarding intraglandular BoNT adverse events in oral health has not yet been systematically assessed.…”