Sialorrea en Pc, manejo con Toxina botulinica

Drooling, i.e., unintentional loss of saliva from the mouth is uncommon after the age of four [1]. However, in children with CP who may have mental and physical disabilities and abnormalities in facial morphology, dental malocclusion and open mouth posture, drooling is present in 40% at the age of 7–14 years and considered severe in 15% [1,2,3]. Anterior drooling is typically present outside meals and is classified either as anterior drooling over the lip margin or posterior with coughing and aspiration. It is associated with a great inconvenience for the children and their family and may be considered as more or less socially unacceptable when saliva runs down over the chin and makes clothes wet. Drooling caused by increased secretion is defined as primary sialorrhea, which in children may be related to irritation of the oral mucosa, teething or side effects of pharmacologic treatment. Conversely, secondary sialorrhea is drooling associated with an increased amount of saliva in the mouth due to insufficient drainage. Drooling in children with CP is often secondary sialorrhea, i.e., most likely caused by oral motor dysfunction [4]. The submandibular glands secrete the majority of UWS, whereas the parotid contributes equally during stimulation from mastication and taste. The salivary flow is assessed by draining, spitting, suction and swab methods in roughly equivalent values. The swab method is the least reliable but the best choice in patients with poor ability to cooperate [5]. In healthy children 6–11 years of age, unstimulated whole saliva (UWS) measured by the swab method is 0.63 mL/min (range 0.14–1.30 mL/min) [6].Many types of interventions have been used in children to reduce their drooling. These include surgery, medicine, intraglandular injection with botulinum toxin (BoNT-A and BoNT-B), and physiotherapy, training to improve sensory function, behavioral therapy for better drooling control, oral appliances, and acupuncture. In a Cochrane review, there was insufficient evidence to recommend one intervention over others [7]. However, a later evidence-based review supported the use of BoNT for sialorrhea and concluded that secretion and drooling were reduced 3–9 months after injections into the salivary glands [8]. To avoid misplacement and for safety reasons, injections of BoNT should be performed with guidance from ultrasound instead of anatomical landmarks, and careful assessment of the children should be carried out prior to the treatment [2]. The mechanism of BoNT is a prolonged transient inhibition of the parasympathetic synaptic transmission without neurodegeneration and interference with the release of norepinephrine from sympathetic nerve endings [9,10,11,12]. In addition, it is associated with changes in the composition of saliva and the saliva increased thickness 6–8 weeks post-treatment.
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