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During the process of the multiple sclerosis (MS), persons with multiple sclerosis (PwMS) may experience drooling (sialorrhea) issues that are frequently disregarded. The exact cause of drooling in PwMS is poorly understood. This study aims to assess potential risk factors for drooling seen in PwMS. The study included 20 PwMS with drooling and 19 PwMS without drooling. The participants' sociodemographic data and clinical parameters were noted. To evaluate dysphagia, fatigue, and hypersalivation, the Dysphagia in Multiple Sclerosis Questionnaire (DYMUS), the Fatigue Severity Scale (FSS), and objective saliva flow rate measurement with cottons placed in Stensen ducts and under the tongue (swab test) were used, respectively. The study employed univariate and multivariate logistic regression models to identify the risk factors linked to drooling. Gender, age, disease duration, MS type, and Expanded Disability Status Scale scores did not differ between the two groups. There was a significant increase in the DYMUS and submandibular/sublingual (SM/SL) saliva flow rate values in PwMS with drooling (p = 0.009 and p = 0.019, respectively). However, in our study, hypersalivation was not observed in PwMS with or without drooling. In the univariate model, DYMUS, SM/SL saliva flow rate, and FSS were found to be risk factors for drooling in PwMS. But only DYMUS was shown to be a significant risk factor in the multivariate model obtained by the backward (Wald) elimination method (p = 0.023). Finally, our research is the first to demonstrate the relationship between drooling and the presence of dysphagia symptoms in PwMS. This is a very important study to determine the nature of drooling in PwMS. This finding shows that our study will serve as a reference for choosing the best method for drooling treatment. [ABSTRACT FROM AUTHOR]

A 14‐year‐old spayed female Miniature Pinscher presented with tongue curling, dysphagia, hypersalivation, and sublingual gland swelling. Comprehensive evaluation, including neurologic and musculoskeletal examinations, blood work, and urinalysis, revealed no abnormalities other than tongue‐related signs. Magnetic resonance imaging (MRI) revealed a multilobed cystic structure in the occipito‐atlanto‐axial joint, compressing the right hypoglossal canal. The lesion appeared cerebrospinal fluid (CSF)‐like on T1‐weighted and T2‐weighted images, and hyperintense compared with CSF on fluid‐attenuated inversion recovery T2‐weighted images. The scans suggested mucinous content with enhanced peripheral areas on contrast‐enhanced images. Surgical removal and drainage of this cyst were performed, and clinical signs improved markedly. The dorsal cyst was tentatively diagnosed as a ganglion cyst based on histopathologic and imaging findings. Ganglion cysts should be considered in the differential diagnosis for dogs with similar MRI findings and neurologic signs. [ABSTRACT FROM AUTHOR]

Abstract A 14‐year‐old spayed female Miniature Pinscher presented with tongue curling, dysphagia, hypersalivation, and sublingual gland swelling. Comprehensive evaluation, including neurologic and musculoskeletal examinations, blood work, and urinalysis, revealed no abnormalities other than tongue‐related signs. Magnetic resonance imaging (MRI) revealed a multilobed cystic structure in the occipito‐atlanto‐axial joint, compressing the right hypoglossal canal. The lesion appeared cerebrospinal fluid (CSF)‐like on T1‐weighted and T2‐weighted images, and hyperintense compared with CSF on fluid‐attenuated inversion recovery T2‐weighted images. The scans suggested mucinous content with enhanced peripheral areas on contrast‐enhanced images. Surgical removal and drainage of this cyst were performed, and clinical signs improved markedly. The dorsal cyst was tentatively diagnosed as a ganglion cyst based on histopathologic and imaging findings. Ganglion cysts should be considered in the differential diagnosis for dogs with similar MRI findings and neurologic signs.

Sialorrhea, defined as an excess flow of saliva or excessive secretions, is common in patients with cerebral palsy and other neurologic disorders and is associated with clinical complications such as increased risk of local skin reactions, infections, aspiration, pneumonia, and dehydration. Upon failure of non-pharmacologic measures, clinicians have several noninvasive pharmacologic options available to manage sialorrhea. This review of the literature provides detailed descriptions of medications used, efficacy, safety, and practical considerations for use of non-injectable pharmacologic agents. The literature search included published human studies in the English language in PubMed and Google Scholar from 1997 to 2022. Relevant citations within articles were also screened. A total of 15 studies representing 719 pediatric patients were included. Glycopyrrolate, atropine, scopolamine, and trihexyphenidyl all have a potential role for sialorrhea management in children; however, glycopyrrolate remains the most studied option with 374 (n = 52.0%) of the 719 patients included in the systematic review receiving this medication. Overall, glycopyrrolate showed similar efficacy but higher tolerability than its comparators in 2 comparative studies and is often considered the first-line agent. Patient-specific (age, route of administration) and medication-specific (dosage formulation, medication strength) considerations must be weighed when initiating a new therapy or switching to another medication upon treatment failure. Owing to the high propensity of adverse events with all agents, clinicians should consider initiating doses at the lower end of the dosage range, as previous studies have noted a dose-dependent relationship. [ABSTRACT FROM AUTHOR]

Sialorrhea is defined as a chronic excessive flow of saliva from the mouth, often with adverse consequences for health and quality of life of patients. In addition to currently used non-drug treatment and systemic drugs, intraglandular Botulinum Neurotoxin A (BoNT/A) injections have been examined in case studies, controlled trials and clinical practice. Two pivotal Phase III trials recently led to market approval in the USA and EU for IncobotulinumtoxinA [Xeomin®, IncoBoNT/A, Clostridium botulinum neurotoxin type A (150 kD), free from complexing proteins, Merz Pharmaceuticals GmbH] for treatment of chronic sialorrhea in adults and pediatric patients. This review provides a multidisciplinary approach to discuss the current state of sialorrhea therapy as well as benefits and current limitations of BoNT/A injections. A consensus regarding treatment recommendations made available to physicians in Germany in 2022 has now been updated here for presentation to an international audience. This review provides a framework including a flow chart for patient selection, recommendations for dosing and the injection process, as well as a discussion of therapeutic goals, long-term benefits and safety aspects. This review is aimed at supporting physicians in developing multidisciplinary and individualized treatment approaches to achieve optimal benefits for patients.

Parkinson's disease (PD) is a chronic, progressive neurological disorder and the second most common neurodegenerative condition. We report three common but overlooked symptoms in PD—hiccups, hypersalivation, and hallucinations—in terms of their prevalence, pathophysiology, and up-to-date evidence-based treatment strategies. Whilst all these three symptoms do occur in many other neurological and non-neurological conditions, early recognition and treatment are paramount. Whilst hiccups affect 3% of healthy people, their rate of occurrence is higher (20%) in patients with PD. Hypersalivation (Sialorrhea) is another common neurological manifestation of many neurological and other neurodegenerative conditions such as motor neuron disease (MND), with a median prevalence rate of 56% (range: 32–74%). A 42% prevalence of sialorrhea is also reported in sub-optimally treated patients with PD. Hallucinations, especially visual hallucinations, are commonly reported, with a prevalence of 32–63% in PD, and a 55–78% prevalence is noted in patients with dementia with Lewy bodies (DLB), followed by tactile hallucinations, which are indicated by a sensation of crawling bugs or imaginary creatures across the skin surface. Whilst mainstay and primary management strategies for all these three symptoms are carried out through history taking, it is also essential to identify and treat possible potential triggers such as infection, minimise or avoid causative (such as drug-induced) factors, and especially carry out patient education before considering more definitive treatment strategies, such as botulinum toxin therapies for hypersalivation, to improve the quality of life of patients. This original review paper aims to provide a comprehensive overview of the disease mechanisms, pathophysiology, and management of hiccups, hypersalivation, and hallucinations in Parkinson's disease. [ABSTRACT FROM AUTHOR]

A ten-year-old indoor, castrated male Cardigan Welsh Corgi (Canis familiaris) presented with the chief complaints of chronic vomiting, retching, hypersalivation, and bilateral submandibular masses for two months. The systemic examinations, including serum chemistry, radiography, ultrasonography, and fluoroscopy, were unremarkable. A fine-needle aspiration revealed bilateral submandibular sialadenitis. Broad-spectrum antibiotics with phenobarbital were prescribed to alleviate the ptyalism. Thereafter, the left submandibular glands were normalised, and the right submandibular glands decreased to half their size. Three weeks later, the animal had an emergency visit because of a sudden left exophthalmos. Computed tomography and magnetic resonance imaging revealed enlarged left zygomatic and right mandibular salivary glands. The affected glands were surgically removed; the histopathologic examination confirmed non-septic sialadenitis, and the patient was finally diagnosed with idiopathic sialadenitis. Vomiting continued after the gland removal and the dog required a gradual increase in the phenobarbital dosage and an additional antiepileptic drug (potassium bromide) to manage the symptoms. The patient died eight months later from an unknown cause. This case report of bilateral submandibular sialadenitis concurrent with unilateral zygomatic sialadenitis in a Welsh Corgi dog suggests that when multiple salivary glands are involved, the response to anti-epileptic drugs and the prognosis is poor compared to that involving a single salivary gland.

A 6‐year‐old, male, neutered Dalmatian was evaluated as an emergency due to retching, hypersalivation and haematemesis, which developed after ingestion of medium‐density fibreboard. Radiographs of the neck, thorax and abdomen revealed gas tracking within the cervical oesophageal wall. Endoscopy revealed changes suggestive of severe generalised oesophagitis, oesophageal laceration in caudal oesophagus and gastritis. Treatment with prokinetics, antiemetics, gastroprotectants and antibiotics was administered. However, progressive regurgitation noticed 4 weeks after discharge prompted a second endoscopy, which excluded oesophageal stricture but confirmed persistent severe oesophagitis. Aspiration pneumonia occurred 4 weeks later after an episode of suspected regurgitation secondary to quick ingestion of food. Five months after initial presentation, hand‐feeding from a height and administration of metoclopramide and omeprazole were still required to prevent retching and regurgitation. Therefore, permanent damage to the oesophagus associated with ingestion of medium‐density fibreboard was suspected. [ABSTRACT FROM AUTHOR]

Legalization/decriminalization of cannabis will increase the numbers of patients who have had recent exposure to recreational or medical cannabis. Currently, little has been reported about potential interactions between cannabis use and Propofol anesthesia e.g., for oropharyngeal procedures. We describe three cases of ‘cannabis-induced hypersalivation after propofol’ (CHAP) and present our institutions’ experience with this unique pharmacological combination. Increased hypersalivation may complicate procedures and represent a procedural risk of suffocation. We evaluate possible pharmacological interactions that might underlie this phenomenon and consider management options going forward.

Abstract Objective The objective of the study is to explore the long-term effectiveness and tolerability of metoclopramide in the treatment of CIH. Method This study is a retrospective, observational cohort study of patients prescribed metoclopramide for CIH at the South London & Maudsley (SLaM) NHS Foundation Trust. Results Of the 96 patients identified, 14 patients were eligible for inclusion in our study. Five patients continued treatment with a mean duration of 27 months (SD = 17.8), and one patient continued until transfer with a duration of 3 months. Eight patients discontinued treatment after a mean duration of 8 months. Conclusion Metoclopramide may be an effective and tolerated drug in CIH, but more data is required to establish its place in the pharmacotherapy of this condition.

Background Hypersalivation is a major side-effect of clozapine in patients with treatment-resistant schizophrenia. Aims We investigated the efficacy of topical anticholinergic formulation sofpironium bromide gel for improving hypersalivation in patients with treatment-resistant schizophrenia receiving clozapine. Method A double-blind, controlled crossover study was conducted with sofpironium bromide gel and a placebo gel to treat clozapine-induced hypersalivation in 16 patients with treatment-resistant schizophrenia. Patients were randomly divided between groups A and B (each n = 8). Group A was treated with sofpironium bromide gel for 6 weeks, followed by a 2-week washout period and 6 weeks of placebo gel, after which they were observed for another 2 weeks. In contrast, group B was treated with placebo gel for 6 weeks, followed by a 2-week washout period, 6 weeks of sofpironium bromide gel and a 2-week observation period. One-minute saliva volume, objective salivation ratings (Drooling Severity and Frequency Scale and Nocturnal Hypersalivation Rating Scale) and subjective salivation ratings (Visual Analogue Scale) were assessed every 2 weeks. Results All patients completed the trials. Three patients reported mild, spontaneously resolved skin itching. Compared with baseline values, the 1-min saliva volumes of both groups were significantly decreased by approximately 30% at the second week of sofpironium bromide gel treatment (P < 0.001), and significantly decreased by >40% at the fourth and sixth weeks of treatment (P < 0.001). The effects were maintained for over 2 weeks even after the treatment was discontinued. Conclusions We suggest that sofpironium bromide gel is effective in treating clozapine-induced hypersalivation in patients with treatment-resistant schizophrenia.

Saliva is a complex fluid produced by the salivary glands in the mouth. The large salivary glands are responsible for producing 93% of saliva and the small salivary glands for the remaining 7%. The remaining one percent of saliva is made up of various inorganic and organic compounds. Both the amount and quality of saliva are important. The components of saliva and the functions they play in maintaining dental health will be reviewed, as will saliva's relevance in caries development and bacterial plaque formation, as well as its diagnostic usefulness for certain illnesses. Several physiological and pathological factors may have a temporary or permanent effect on salivary flow. The mouth and its components rely heavily on saliva for a variety of reasons, including immunity against oral infections, proper digestion, and pleasant social interactions. By diluting and flushing away sugars and other substances, serving as a buffer, controlling demineralization and remineralization, and inhibiting microbial development, saliva plays an important role in avoiding dental cavities. The use of saliva as a diagnostic tool, therapy monitor, and therapeutic outcome predictor has been proposed. It is a convenient diagnostic technique because of the strong positive relationship between many serum and saliva indicators and its ease of use. [ABSTRACT FROM AUTHOR]

Objective: This review summarizes the approaches to pediatric sialorrhea management from least-to-most invasive: non-pharmacological management, anticholinergic medications, botulinum neurotoxin, non-invasive surgery, and invasive surgical intervention., Review Methods: An electronic literature review identified English-language articles on sialorrhea management in pediatric patients. Publications between 1982 and 2022 were used, with a focus on articles published from 2012 to 2022. Additional augmentation of pharmacologic information was obtained from the latest editions of medical textbooks supplemented with official package inserts of investigated medications., Conclusions: Sialorrhea is abnormal in patients greater than four years of age. Severe cases warrant intervention to improve patient quality of life and reduce caregiver burden. Management starts with conservative approaches. Viable candidates begin with non-pharmacological management options. Anticholinergic medications can decrease saliva production, but adverse side effects may outweigh benefits. Botulinum neurotoxin injection of the salivary glands decreases salivary flow rate; however, relief is transient and thus multiple treatments are required. Non-invasive sclerotherapy is an emerging treatment option showing promising results for sialorrhea. In contrast, surgical intervention is reserved as a last-resort treatment for patients with severe symptoms, due to its higher risk for adverse consequences., Implications for Practice: Physicians should be familiar with the different pediatric sialorrhea management options, including advantages and disadvantages, to adequately facilitate shared decision making with caretakers of pediatric patients who require treatment., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

A ten-year-old indoor, castrated male Cardigan Welsh Corgi (Canis familiaris) presented with the chief complaints of chronic vomiting, retching, hypersalivation, and bilateral submandibular masses for two months. The systemic examinations, including serum chemistry, radiography, ultrasonography, and fluoroscopy, were unremarkable. A fine-needle aspiration revealed bilateral submandibular sialadenitis. Broad-spectrum antibiotics with phenobarbital were prescribed to alleviate the ptyalism. Thereafter, the left submandibular glands were normalised, and the right submandibular glands decreased to half their size. Three weeks later, the animal had an emergency visit because of a sudden left exophthalmos. Computed tomography and magnetic resonance imaging revealed enlarged left zygomatic and right mandibular salivary glands. The affected glands were surgically removed; the histopathologic examination confirmed non-septic sialadenitis, and the patient was finally diagnosed with idiopathic sialadenitis. Vomiting continued after the gland removal and the dog required a gradual increase in the phenobarbital dosage and an additional antiepileptic drug (potassium bromide) to manage the symptoms. The patient died eight months later from an unknown cause. This case report of bilateral submandibular sialadenitis concurrent with unilateral zygomatic sialadenitis in a Welsh Corgi dog suggests that when multiple salivary glands are involved, the response to anti-epileptic drugs and the prognosis is poor compared to that involving a single salivary gland. [ABSTRACT FROM AUTHOR]

Purpose: The purpose is to analyze the incidence of acute infectious supraglottitis in our center between 2010 and 2020, define the characteristics and trends of those patients and identify factors associated with the need of airway intervention. Methods: A retrospective single-center observational study of a cohort of patients diagnosed with acute infectious supraglottitis between January 2010 and December 2020. Patients were stratified according to airway management. Results: Eighty eight patients were included: 59 men (67%) and 29 women (33%). A significant upward trend of 9% in the annual incidence rate of supraglottitis was seen during 2010–2020, with an important increase in cases during 2019. Muffled voice (41%) and respiratory distress (38%) were the most common presenting symptoms; and the median duration of symptoms before hospital admission was 2 days [IQR 1; 3]. Airway intervention was performed in fifteen patients (17%). Nine patients (10%) were intubated and six required tracheotomy (7%). Comparing the patients who required airway intervention with those who received a conservative treatment, younger patients (p < 0.01) were more likely to need airway intervention. In logistic regression analysis, we found that epiglottic abscess (p = 0.015), hypersalivation (p = 0.027) and smoking (p = 0.036) were independent factors with a significant association with airway intervention. Conclusion: There was an important increase in cases and its severity in 2019, but due to COVID-19 pandemic, it was not possible to define if it was an isolate event or an upward trend. Epiglottic abscess, hypersalivation and smoking could be possible risk factors for airway intervention. [ABSTRACT FROM AUTHOR]

Legalization/decriminalization of cannabis will increase the numbers of patients who have had recent exposure to recreational or medical cannabis. Currently, little has been reported about potential interactions between cannabis use and Propofol anesthesia e.g., for oropharyngeal procedures. We describe three cases of 'cannabis-induced hypersalivation after propofol' (CHAP) and present our institutions' experience with this unique pharmacological combination. Increased hypersalivation may complicate procedures and represent a procedural risk of suffocation. We evaluate possible pharmacological interactions that might underlie this phenomenon and consider management options going forward. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study is to explore the long-term effectiveness and tolerability of metoclopramide in the treatment of CIH. Method: This study is a retrospective, observational cohort study of patients prescribed metoclopramide for CIH at the South London & Maudsley (SLaM) NHS Foundation Trust. Results: Of the 96 patients identified, 14 patients were eligible for inclusion in our study. Five patients continued treatment with a mean duration of 27 months (SD = 17.8), and one patient continued until transfer with a duration of 3 months. Eight patients discontinued treatment after a mean duration of 8 months. Conclusion: Metoclopramide may be an effective and tolerated drug in CIH, but more data is required to establish its place in the pharmacotherapy of this condition. [ABSTRACT FROM AUTHOR]

Aim of the study The present paper aims to achieve a brief presentation of the oral health problems derived from the long-term administration of the psychotropic medication, in order to emphasize the importance of educating the population and the health specialists how to prevent the oral pathology that can lead to various disabilities, further reducing the quality of life of the patient with mental disorders with chronic evolution. Material and methods The article is structured as a synthesis of recent literature, published in prestigious magazines. Results The results of these studies show that almost all psychiatric medicines, especially antipsychotics, antidepressants and timostabilizers, most commonly cause xerostomia, sialorrhea, implicit dental caries or gingival bleeding. Conclusions Knowing these complications from the oral sphere, medically induced in patients undergoing long-term psychiatric treatment, may lead to the establishment of adequate preventive measures, thus increasing the quality of life of the patients and thus avoiding the more serious complications arising from persistent adverse effects.

Sialorrhea, also known as hypersalivation, ptyalis, or drooling, results in physical and psychosocial complications that may have a significant negative impact on quality of life for both the patient and their caregiver. The goal of pharmacological treatment is to reduce excessive salivary flow, while maintaining a moist and healthy oral cavity; until recently, however, few of the agents used to treat chronic sialorrhea have been approved in pediatric patients. This article summarizes early evidence for the use of botulinum neurotoxin A formulations in the treatment of children/adolescents with chronic sialorrhea, and findings of the recently completed phase III trial of incobotulinumtoxinA in this indication. Alternative therapies are also briefly discussed. IncobotulinumtoxinA is the first botulinum neurotoxin A to be approved for the treatment of chronic sialorrhea in children and adults, following the results of phase III trials that demonstrate the efficacy and safety of the drug in these patients. The authors expect that the positive findings will result in updates to clinical guidelines for the treatment of children with chronic sialorrhea. AE, adverse event; AESI, adverse event of special interest; BoNT/A, botulinum neurotoxin A; CI, confidence interval; CP, cerebral palsy; DIS, drooling impact scale; DQ, drooling quotient; DSFS, Drooling Severity and Frequency Scale; GICS, Global Impression of Change Scale; LS, least squares; mTDS, modified Teacher's drooling scale; NR, not reported; PD, Parkinson's disease; SAE, serious adverse event; SE, standard error; SIAXI, Sialorrhea in Adults Xeomin Investigation; SIPEXI, Sialorrhea Pediatric Xeomin Investigation; SNAP-25, synaptosomal associated protein-25; TBI, traumatic brain injury; TDS, Teacher Drooling Scale; USA, United States of America; uSFR, unstimulated Salivary Flow Rate; VAS, visual analog scale [ABSTRACT FROM AUTHOR]

Background: Arizona's rugged desert landscape harbors many venomous animals, including a small nocturnal scorpion, Centruroides sculpturatus, whose venom can cause severe neuromotor disturbance. An effective antivenom is available at selected health care facilities in the state.Methods: We analyzed 4398 calls of scorpion stings to the Arizona Poison and Drug Information Center (APDIC) in Tucson over a period of 3 years, from January 2017 to December 2019.Results: We followed 1952 (44.4%) of the victims to resolution. We excluded 2253 callers with minimal effects of the sting and 193 victims with possible toxic effects who were lost to follow-up. The most common complaints among callers were pain at the sting site in 88.9% and local numbness in 62.2%. Detailed clinical information was obtained from 593 calls from a health care facility. Neuromotor signs consistent with C. sculpuratus envenomation included nystagmus in 163 (27.5%), hypersalivation in 91 (15.3%), and fasciculations in 88 (14.8%). Antivenom (Anascorp; Rare Disease Therapeutics, Inc., Franklin, Tenn) was administered to 145 patients. Most were children <5 years old (n = 76, or 54.4%); 27 (18.6%) were 5-9 years old and 42 (30.0%) were ≥10 years of age. About half, 79 of 145 (54.5%) victims who received antivenom, met the APDIC recommended use criteria.Conclusions: Patients treated with antivenom exhibited a rapid resolution of symptoms without immediate or delayed hypersensitivity reactions. We recommend broadened availability of antivenom at sites where it is most needed. [ABSTRACT FROM AUTHOR]

Sialorrhea is the uncontrolled leakage of saliva outside the mouth. This term commonly refers to anterior sialorrhea and should be distinguished from posterior sialorrhea, in which saliva spills through the oropharynx into the hypopharynx. It is considered pathologic beyond the age of four years. Chronic sialorrhea is seen in children with abnormal oral sensation and/or motor control and more infrequently when there is excessive production of saliva. Sialorrhea can lead to functional and clinical consequences for children, families and caregivers. In most cases, sialorrhea can be diagnosed from a history and physical examination, and additional investigation is usually unnecessary. Management of this disorder is complex and should be addressed by a multidisciplinary team, progressing from conservative to more invasive treatments. The present document intends to review and update the clinical aspects of sialorrhea in children. [ABSTRACT FROM AUTHOR]

Background Administration of botulinum toxin through intraductal salivary infusion may decrease the risks of percutaneous needle injection and improve delivery to permeate the entire gland parenchyma. Methods The safety of intraductal salivary gland infusion was tested with prospective evaluation of two patients using interviews, clinical examination, and pressure measurement during infusion. Retrospective chart review of two subsequently treated patients assessed treatment of a parotid‐cutaneous fistula and sialorrhea. Results No complications were identified in the safety study. Pressure changes during infusion supported the concept of botulinum neurotoxin delivery to permeate the gland. Patient‐assessed success was subjectively reported as a reduction in the parotid‐cutaneous output “by 95%” and the sialorrhea “by 90%” at 2‐week follow‐up. Conclusions The intraductal route of botulinum toxin delivery to salivary glands was without complication and was effective in two patients treated therapeutically. Pressure measurements during infusion may be helpful to direct treatment. Level of Evidence 4

Introduction Mr. X, a 39-year-old man presented to us with a history of alcohol use from the last 12-15 years in a dependence pattern with tolerance, uncomplicated withdrawal symptoms and salience. He was detoxified, given parenteral thiamine supplements and oral lorazepam to reduce withdrawal symptoms. He was contemplating to quit alcohol and thus about 4-5 days after his detoxification, tablet acamprosate 1998 mg/day was added, in three divided dosages. He was discharged after 10 days and had no withdrawal signs or cerebellar deficits. In the next follow-up after two weeks, he reported to be abstinent from alcohol, but now complained of new onset coarse tremors and excessive salivation. He had no other extra pyramidal or cerebellar symptoms, no hepatic or renal dysfunction and no neurological deficits. The Patient had a drooling score of 6 on Drooling Severity and Frequency Scale(DSFS). Objectives Acamprosate and naltrexone are the only two drugs approved by the US Food and Drug Administration for achieving abstinence in patients with Alcohol Dependence Syndrome. Acamprosate is well tolerated and has a few drug interactions. It has a comparatively benign side effect profile which includes diarrhea, intestinal cramps, itching, dizziness, muscle weakness, headache, flatulence, nausea, anxiety, and insomnia. Here we report hypersalivation and coarse tremors as unusual side effects of acamprosate. Methods Cross-sectional Results Here we report hypersalivation and coarse tremors as unusual side effects of acamprosate. Conclusions The probable mechanism responsible for this is thought to be acamprosate induced decrease in dopamine release in ventral tegmental area due to diminished glutamate activity. Disclosure No significant relationships.

Summary: The objective of this case report is to describe the diagnostic and surgical techniques for removal of a metallic foreign body in the tongue of three adult horses. The three horses were presented for evaluation and treatment of dysphagia and marked hypersalivation of 3–5 days duration. Radiographs of the head revealed the presence of a metallic foreign body in the tongue of each horse. The foreign bodies could be precisely localised under general anaesthesia using palpation and lingual ultrasonography and/or lingual radiography in combination with a forceps as a marker. The foreign bodies were successfully removed using laparoscopic instruments creating minimal soft tissue trauma. The use of long (43 cm) small laparoscopic (5 mm) instruments enabled good visualisation of the surgical field, providing optimal conditions for successful minimally invasive surgical treatment of horses with foreign bodies in the tongue. The three horses made uneventful recoveries and 12 months after surgery were eating normally and could be ridden with a bit as per usual routine. It was concluded that using long laparoscopic instruments in combination with palpation, ultrasonography and/or radiography allowed removal of the foreign body creating minimal soft tissue trauma and allowing optimal conditions for a fast recovery. [ABSTRACT FROM AUTHOR]

(1) Background: Clozapine is the most effective antipsychotic. It is, however, associated with many adverse drug reactions. Nose-to-brain (N2B) delivery offers a promising approach. This study aims to develop clozapine-encapsulated thermosensitive sol–gels for N2B delivery. (2) Methods: Poloxamer 407 and hydroxypropyl methylcellulose were mixed and hydrated with water. Glycerin and carbopol solutions were added to the mixture and stirred overnight at 2–8 °C. Clozapine 0.1% w/w was stirred with polysorbate 20 (PS20) or polysorbate 80 (PS80) at RT (25 °C) before being added to the polymer solution. The final formulation was made to 10 g with water, stirred overnight at 2–8 °C and then adjusted to pH 5.5. (3) Results: Formulations F3 (3% PS20) and F4 (3% PS80) were selected for further evaluation, as their gelation temperatures were near 28 °C. The hydrodynamic particle diameter of clozapine was 18.7 ± 0.2 nm in F3 and 20.0 ± 0.4 nm in F4. The results show a crystallinity change in clozapine to amorphous. Drug release studies showed a 59.1 ± 3.0% (F3) and 53.1 ± 2.7% (F4) clozapine release after 72 h. Clozapine permeated after 8 h was 20.8 ± 3.0% (F3) and 17.8 ± 3.1% (F4). The drug deposition was higher with F4 (144.8 ± 1.4 µg/g) than F3 (110.7 ± 2.7 µg/g). Both sol–gels showed no phase separation after 3 months. (4) Conclusions: Binary PS80-P407 mixed micelles were more thermodynamically stable and rigid due to the higher synergism of both surfactants. However, binary mixed PS20-P407 micelles showed better drug permeation across the nasal mucosa tissue and may be a preferable carrier system for the intranasal administration of clozapine.

Background: Benign childhood epilepsy with centrotemporal spikes (BECTS) also called Benign Rolandic Epilepsy (BRE) is a common form of childhood epilepsy syndrome. It often occurs during sleep and is characterized by episodes of simple partial motor seizures of the face and/or oropharynx. The aim of this study is to investigate the most common seizure semiology associated with BRE and the role of electroncephalogram (EEG) in this childhood epilepsy syndrome. Aim and Methods: In this study we conducted a retrospective chart review of patients with BRE who presented to Bahrain Defense Force Hospital (BDF), Kingdom of Bahrain during the period of January 2017 to December 2019. Sixty-nine children were included. Their demographics, description of seizure semiology and their EEG findings were analyzed using descriptive statistical analysis on SPSS and the results are presented in pie and bar charts. Results: Out of 69 children who were diagnosed with BRE, 36 (52.1%) were found to be males indicating male gender predominance. the average age of the first episode was found to be of 6 years. Most of the patients had their seizures while asleep (88.4%) and we also identified focal seizure as the most common semiology associated with BRE accounting for 61 (88.4%) children followed by hypersalivation 7 (10.1%). We discovered that abnormal EEG findings were found in 45 (65.2%) of total sample size. Out of these, 28 (62.2%) had centrotemporal epileptiform spikes and wave discharges. The other findings that were found in our study demonstrate the important role of EEG in diagnosing BRE and the importance of further future studies. Conclusion: Most common semiology was focal seizure followed by hypersalivation. The majority of EEG's were abnormal with the commonest finding being centrotemporal epileptiform spike and wave discharges. [ABSTRACT FROM AUTHOR]

Background: Hypersalivation and drooling are commonly reported in clozapine-treated patients. Current management strategies have been evaluated using subjective measures. Many case reports describe the successful use of atropine in the treatment of the condition. Aims: To measure the effect and safety of sublingual atropine on nocturnal unstimulated saliva secretion. Secondary aims were to evaluate the patient's satisfaction with the atropine effect on hypersalivation (or sialorrhea), drooling, and sleep. Method: Twenty-one clozapine-treated patients with hypersalivation, or drooling, were randomised to take a single 600-μg dose of sublingual atropine drops or a matching placebo. The saliva secretion was measured over 5 min at baseline and 2 h after the administration of the study medication. Results: Sublingual atropine reduced the saliva secretion significantly more than the placebo (mean difference = − 57.21%, 95% CI: − 104.30, − 10.11, P = 0.02). A significant decrease in standing pulse rate was recorded in the participants in the atropine group (− 5.8 (− 9.54, − 2.15), P = 0.002). Subjectively, more patients in the atropine group found their pillow to have less saliva the following morning and found their sleep to be better. Conclusions: Sublingual atropine drops significantly reduces nocturnal unstimulated clozapine-induced saliva secretion. More research is required to compare the effect of sublingual atropine with other anticholinergic medications and different dosage forms. Trial registration: ACTRN12618000051246 [ABSTRACT FROM AUTHOR]

Introduction: Saliva problems are common and distressing for people with motor neuron disease (pwMND). Despite clinical guidelines for assessment and treatment, management of saliva problems has received little research attention. Objective: We aimed to investigate the prevalence of saliva problems in pwMND, their association with clinical factors, and their management practice using a highly curated population-based register for motor neuron disease (MND) with 99% case ascertainment. Methods: We conducted an analysis of pwMND diagnosed between January 2015 and October 2019 using the Scottish MND Register (CARE-MND [Clinical, Audit, Research, and Evaluation of MND]). The association between clinical factors and saliva problems was investigated using univariate and multivariable logistic regression; results are reported as odds ratio (OR) and 95% confidence intervals. A survey of health-care professionals involved in the care of pwMND was performed to contextualize the findings. Results: 939 pwMND were included. Prevalence of saliva problems was 31.3% (294). Bulbar onset (OR 9.46 [4.7, 19.2]; p < 0.001) but not age, sex, time to diagnosis, or MND subtype were independently associated with the presence of saliva problems in multivariable regression, and 52.7% (155) of those with saliva problems received pharmacological management. The most commonly used medications were hyoscine, amitriptyline, carbocisteine, glycopyrrolate, and atropine. Evidence base (8, 72.7%) and local guidelines (10, 90.9%) were cited as the most important factors influencing treatment decision by survey respondents (n = 11). Conclusion: Saliva problems are common and associated with bulbar onset MND. A substantial proportion of pwMND with saliva problems did not receive recommended treatments. Future research is required to determine the relative efficacy of individual pharmacological treatments. [ABSTRACT FROM AUTHOR]

Background: Sialorrhea is a troublesome symptom in a variety of neurological diseases. Recently, local injection of botulinum toxin into the salivary glands was approved for treatment of sialorrhea, and injection guidance by anatomical landmarks was suggested. Objective: To compare the accuracy of ultrasound versus previously proposed anatomical landmarks for localizing the salivary glands. Methods: In a cross‐sectional study in 21 adults, landmark positions (LM) of the parotid gland (PG) and the submandibular gland (SG) were identified following published recommendations. The ultrasound position (US) was defined as the position representing the maximum gland thickness. The distance between positions, gland thickness, and optimal injection depth were recorded by US. Results: Gland thickness differed significantly between LM and US positions (PG, 4 vs. 17.8 mm; P < 0.001; SG, 3.5 vs. 13.6 mm; P < 0.001). The spatial deviation between the recommended LM and identified US positions in the horizontal plane was 21 mm to the posterior direction for the PG and 19.6 mm for the SG. The deviation in vertical orientation was small for both glands; however, there was a positive correlation between the distance from the SG to the mandibular bone with age. The optimal injection depth measured by US was 11.8 mm for the PG and 13.6 mm for the SG. This showed to be positively correlated with the body mass index. Conclusions: The position of the salivary glands differs from proposed landmarks and depends on the individual age and body weight; therefore, we recommend ultrasound guidance for injection. [ABSTRACT FROM AUTHOR]

Clozapine-induced sialorrhea (CIS) is a common, treatment-limiting, and stigmatizing side effect. All systemic agents that are used for CIS may increase clozapine side effects such as blood pressure changes, constipation, or arrhythmias or may have a negative impact on cognition. Sublingual application of antimuscarinic medications might be a low side effect option for treatment of CIS. Our aim is to propose an off-label treatment option of tropicamide ophthalmic solution given orally via sublingual route for CIS and stimulate further examination. A 33-year-old male inpatient with schizophrenia had been on clozapine 800 mg and amisulpride 600 mg per day. His drooling was occasional and severe as drool dripped off his chin during the day and night. Tropicamide 1% (1 mg/ml) ophthalmic solution was applied orally via sublingual route 1–2 drops at each side of his mouth before going to bed as monotherapy for CIS. Wet area over the pillow, Visual Analogue Scale (VAS), Nocturnal Hypersalivation Rating Scale, the MOS 36-Item Short-Form Health Survey (SF-36), Udvalg for Kliniske Undersøgelser Side Effect Rating Scale, the Scale for the Assessment of Negative Symptoms, and the Scale for the Assessment of Positive Symptoms were administered at baseline visit and at one-week intervals. No side effects were observed. On VAS, the patient rated his sialorrhea 5/7 at baseline, 4/7 after one 1 drop, and 3/7 after 2 drops. Nocturnal hypersalivation yielded score 4 before tropicamide was initiated. After 1 drop of tropicamide at each side of the mouth, the score was 3 and after 2 drops at each side, it was 2. Tropicamide ophthalmic solution might present as a low side effect, off-label option for treatment of CIS. The promising effect should be examined by randomized controlled trials to translate this into clinical practice.

Sialorrhea is defined as a chronic excessive flow of saliva from the mouth, often with adverse consequences for health and quality of life of patients. In addition to currently used non-drug treatment and systemic drugs, intraglandular Botulinum Neurotoxin A (BoNT/A) injections have been examined in case studies, controlled trials and clinical practice. Two pivotal Phase III trials recently led to market approval in the USA and EU for IncobotulinumtoxinA [Xeomin®, IncoBoNT/A, Clostridium botulinum neurotoxin type A (150 kD), free from complexing proteins, Merz Pharmaceuticals GmbH] for treatment of chronic sialorrhea in adults and pediatric patients. This review provides a multidisciplinary approach to discuss the current state of sialorrhea therapy as well as benefits and current limitations of BoNT/A injections. A consensus regarding treatment recommendations made available to physicians in Germany in 2022 has now been updated here for presentation to an international audience. This review provides a framework including a flow chart for patient selection, recommendations for dosing and the injection process, as well as a discussion of therapeutic goals, long-term benefits and safety aspects. This review is aimed at supporting physicians in developing multidisciplinary and individualized treatment approaches to achieve optimal benefits for patients., Competing Interests: The content of this review was created based on interdisciplinary consultations and cooperation with all authors and the consensus recommendations were developed during three working meetings. Merz Therapeutics GmbH supported these meetings financially but had no further influence on the recommendations and the content of this review. WJ is or was a consultant and speaker for AbbVie, Bial, Desitin, Kyowa Kirin, Stada, UCB, Zambon, Pharm Allergan, Ipsen Pharma, and Merz Therapeutics and was principal investigator of the SIAXI study. TB is a consultant for Merz Therapeutics and Pharm Allergan and a speaker for Merz Therapeutics, Pharm Allergan, and Ipsen. He received speaker and consultant fees from the Pelzerhaken Children’s Center, AbbVie/Allergan, Ipsen Pharma, and Merz Therapeutics. He received research grants from Deutsche Forschungsgemeinschaft (FG2698-2) and Ipsen Pharma. AB received consultant and speaker fees from Allergan/AbbVie, Merz Therapeutics, and Novartis. UB received consultant fees from Merz Therapeutics. CB received speaker and/or consultant fees from AbbVie, Bial, Desitin, Kyowa Kirin, Merz Therapeutics, STADA Pharm, TAD Pharma, UCB, and Zambon. MG received speaker and consultant fees from Merz Therapeutics, MSD, and Bayer Vital. OG-L received speaker and consultant fees from Merz Therapeutics, MEDICE, MEDEL, and Novartis. RL is a speaker for Merz Therapeutics. SP is or was a consultant for Bial, Idorsia, Ipsen, Merz Therapeutics, and TEVA and a speaker from AbbVie, Bayer, Bial, Ipsen, Merz Therapeutics, and Novartis. Furthermore, SP is or was involved in clinical studies (phase II and III) for Bayer, Ipsen, and Syneos Health. CP received honoraria as a speaker and/or consultant from AbbVie, Merz Therapeutics, InfectoPharm, and Olympus. ASc was a consultant and speaker for Allergan/AbbVie, Ipsen, Merz Therapeutics, Proveca, and Medice. ASt is a consultant and speaker for Merz Therapeutics, Inspire Medical, and ZOLL Respicardia. He received speaking honoraria and travel support from Intersect Medical and Clinigen. BW received speaker fees from AbbVie/Allergan, Takeda, Novartis, and Eisai. MW received honoraria as a speaker and/or consultant from AbbVie. SB received speaker fees from Merz Therapeutics, Ipsen Pharma, and Pharm Allergan and consultant fees from Merz Therapeutics and Ipsen Pharma. He was principal investigator of the SIPEXI study. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2023 Jost, Bäumer, Bevot, Birkmann, Buhmann, Grosheva, Guntinas-Lichius, Laskawi, Paus, Pflug, Schroeder, Spittau, Steffen, Wilken, Winterholler and Berweck.)

Background: Administration of botulinum toxin through intraductal salivary infusion may decrease the risks of percutaneous needle injection and improve delivery to permeate the entire gland parenchyma. Methods: The safety of intraductal salivary gland infusion was tested with prospective evaluation of two patients using interviews, clinical examination, and pressure measurement during infusion. Retrospective chart review of two subsequently treated patients assessed treatment of a parotid‐cutaneous fistula and sialorrhea. Results: No complications were identified in the safety study. Pressure changes during infusion supported the concept of botulinum neurotoxin delivery to permeate the gland. Patient‐assessed success was subjectively reported as a reduction in the parotid‐cutaneous output "by 95%" and the sialorrhea "by 90%" at 2‐week follow‐up. Conclusions: The intraductal route of botulinum toxin delivery to salivary glands was without complication and was effective in two patients treated therapeutically. Pressure measurements during infusion may be helpful to direct treatment. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

The objective of this study is to discover whether incobotulinumtoxinA (inco) can reduce relative hypersalivation in patients with amyotrophic lateral sclerosis (ALS). 14 patients with ALS (8 males and 6 females, age 55.4 ± 16.3 years) received ultrasound-guided injection of inco 100 MU in both parotid glands and inco 50 MU in both submandibular glands. Saliva production was gravimetrically measured with three cotton rolls placed in the mouth. Weight increase after 5 min was measured on an electronic scale. Subjective saliva production was registered with drooling frequency scale (DFS) and drooling severity scale (DSS). Saliva production was gravimetrically reduced at week 4 (p = 0.04), week 8 (p = 0.01) but not after week 12 after BT application. DFS was reduced at week 4 (p = 0.04), week 8 (p = 0.02), but not after week 12. DSS was reduced at week 4 (p = 0.03), week 8 (p = 0.04) and week 12 (p = 0.04). Patients in our study did not experience changes in their swallowing patterns or any other safety-relevant events. Inco is effective and well tolerated for saliva reduction in patients with ALS for 8–12 weeks. [ABSTRACT FROM AUTHOR]

Background: Emesis has significant evolutionary value as a defense mechanism against ingested toxins; however, it is also one of the most common adverse symptoms associated with both disease and medical treatments of disease. The development of improved antiemetic pharmacotherapies has been impeded by a shortage of animal models. Methods: The present studies characterized the responses of the squirrel monkey to pharmacologically diverse emetic drugs. Subjects were administered nicotine (0.032‐0.56 mg/kg), lithium chloride (150‐250 mg/kg), arecoline (0.01‐0.32 mg/kg), or apomorphine (0.032‐0.32 mg/kg) and observed for emesis and prodromal hypersalivation. Results: Nicotine rapidly produced emesis and hypersalivation. Lithium chloride produced emesis with a longer time course without dose‐dependent hypersalivation. Arecoline produced hypersalivation but not emesis. Apomorphine failed to produce emesis or hypersalivation. Conclusions: The squirrel monkey is sensitive to drug‐induced emesis by a variety of pharmacological mechanisms and is well‐positioned to examine antiemetic efficacy and clinically important side effects of candidate antiemetic pharmacotherapies. [ABSTRACT FROM AUTHOR]

Objectives: Tooth wear is a common finding in adult patients with dental sleep disorders. The aim of this paper was to review the literature on the possible associations between tooth wear and the following dental sleep disorders: sleep‐related oro‐facial pain, oral moistening disorders, gastroesophageal reflux disease (GERD), obstructive sleep apnoea syndrome (OSAS) and sleep bruxism. Methods: A PubMed search was performed on 1 June 2018 using MeSH terms in the following query: Tooth Wear AND (Facial Pain OR Temporomandibular Joint Disorders OR Xerostomia OR Sialorrhea OR Gastroesophageal Reflux OR Sleep Apnea Syndrome OR Sleep Bruxism). Results: The query yielded 706 reports on tooth wear and the mentioned dental sleep disorders. Several associations between tooth wear and the dental sleep disorders were suggested in the literature. It could be concluded that: (a) tooth wear is associated with dental pain and/or hypersensitivity; (b) oral dryness is associated with tooth wear, oro‐facial pain and sleep bruxism; (c) GERD is associated with tooth wear, oro‐facial pain, oral dryness, OSAS and sleep bruxism; (d) OSAS is associated with oral dryness, GERD and sleep bruxism; and (e) sleep bruxism is associated with tooth wear. Conclusions: Tooth wear is associated with the dental sleep disorders oro‐facial pain, oral dryness, GERD and sleep bruxism. The dental sleep disorders are interlinked with each other, which leads to indirect associations as well, and makes the consequences of each single condition difficult to disentangle. Knowledge of these associations is clinically relevant, but more research is needed to confirm their validity. [ABSTRACT FROM AUTHOR]

Hypersalivation describes a relatively excessive salivary flow, which wets the patient himself and his surroundings. It may result because of insufficient oro-motor function, dysphagia, decreased central control and coordination. This update presents recent changes and innovation in the treatment of hypersalivation. Multidisciplinary diagnostic and treatment evaluation is recommended already at early stage and focus on dysphagia, saliva aspiration, and oro-motor deficiencies. Clinical screening tools and diagnostics such as fiberoptic endoscopic evaluation of swallowing generate important data on therapy selection and control. Many cases profit from swallowing therapy programmes to activate compensation mechanisms as long compliances are given. In children with hypotonic oral muscles, oral stimulation plates can induce a relevant symptom release because of the improved lip closure. The pharmacologic treatment improved for pediatric cases as glycopyrrolate fluid solution (Sialanar®) is now indicated for hypersalivation within the EU. The injection of botulinum toxin into the salivary glands has shown safe and effective results with long-lasting saliva reduction. Here, a phase III trial is completed for incobotulinum toxin A and, in the US, is indicated for the treatment of adult patients with chronic hypersalivation. Surgical treatment should be reserved for isolated cases. External radiation is judged as a safe and effective therapy when using modern 3D techniques to minimize tissue damage. Therapy effects and symptom severity have to be followed, especially in cases with underlying neurodegenerative disease. [ABSTRACT FROM AUTHOR]