DOI: 10.1111/ipd.12156
Association of onabotulinum toxin A treatment with salivary pH and dental caries of neurologically impaired children with sialorrhea BEATRIZ FERRAZ DOS SANTOS1, BASMA DABBAGH1, SAM J DANIEL2 & STEPHANE SCHWARTZ1 1 2
Division of Dentistry, Department of Pediatric Surgery, Montreal Children’s Hospital, Montreal, Quebec, Canada, and Department of Otolaryngology, Head and Neck Surgery, Montreal Children’s Hospital, Montreal, Quebec, Canada
International Journal of Paediatric Dentistry 2016; 26: 45–51 Background. Sialorrhea is a common manifesta-
tion of several neurological disorders. The use of intraglandular onabotulinum toxin A (OBTXA) injection has been recognized to effectively treat sialorrhea. As OBTXA injection reduces salivary flow rate and alters salivary quality, its use may have a detrimental effect on oral health. Aim. To examine the effect of OBTXA injection on caries experience and salivary pH of neurologically impaired children with sialorrhea. Design. Twenty-five children receiving OBTXA treatment and 25 control children were enrolled in the study. Whole saliva was collected to determine salivary pH. All participants underwent an interview on their dietary habits. Dental clinical
Introduction
Sialorrhea or drooling is a common and disabling manifestation of several neurological disorders. It is usually caused by a lack of oral-motor coordination, which leads to saliva accumulation in the mouth. Chronic sialorrhea impacts the quality of life of children by causing clinical and functional complications such as aspiration, oral and perioral infections and skin irritation. Additionally, it can cause impairment in social function and increase the burden of care for caregivers1. The prevalence of moderate to severe sialorrhea in developmentally disabled individuals is estimated at 10–37%2. Correspondence to: Dr Beatriz Ferraz dos Santos, Department of Dental Surgery, Montreal Children’s Hospital, 1040 Atwater Avenue, Montreal, QC H3Z 1X3, Canada. Tel: (514) 4124400; Fax: (514) 412-4369. E-mail: [email protected]
examinations were carried out to evaluate caries experience and oral hygiene level. Results. Overall, mean salivary pH value was significantly lower in the OBTXA group (6.92 0.77) compared with the control group (7.36 0.70). Caries activity was significantly higher in the OBTXA group (P = 0.01). The regression analyses showed a significant association between OBTXA treatment and salivary pH value (P = 0.03). Results from the logistic regression show that dental caries was significantly associated with OBTXA treatment (OR = 1.73, CI = 1.14–27.3). Conclusions. The study showed an intricate relationship between OBTXA treatment and oral findings. Hence, special dental care should be given to children receiving OBTXA treatment.
Many approaches have been used to reduce the amount of drooling. Among them, the use of onabotulinum toxin A (OBTXA) injection into the salivary glands has been recognized as one of the most effective and less invasive treatment3–7. Botulinum toxins are thought to reduce saliva production by inhibiting post-ganglionic acetylcholine release8 leading to a reduction in salivary flow rate9–11 and an alteration of salivary quality12. The effectiveness of OBTXA injection to reduce drooling has been widely published, but there is a paucity of knowledge concerning its effect on oral health. Nevertheless, it is well known that saliva plays an important role in the maintenance of good oral health. Saliva protects the oral mucosa against mechanical damage, helps the balance of the remineralization and demineralization process of the enamel, and has defense functions against pathogenic microorganisms13,14. Saliva
© 2015 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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also acts as a modulator of salivary pH maintaining its values near neutrality (6.7–7.3)15. The major functions of saliva are directly related to its composition and quantity. Saliva contains 99% water and a wide spectrum of proteins, nucleic acids, electrolytes, and hormones13,16. The concentration of these components varies according to the salivary flow17. Generally, a slight decrease in the salivary secretion rate leads to a decrease in sodium, bicarbonate and pH18,19. Lower salivary pH favors the proliferation of cariogenic bacteria by altering the chemical balance of the tooth surface and increasing the solubility of hydroxyapatite18,20. A reduced salivary flow also compromises the removal of food debris in the mouth21. Therefore, a reduction in salivary rate and pH may lead to an increase in caries activity. The aim of this study was to examine the effect of OBTXA injection on caries experience and salivary pH of neurologically impaired children with a medical diagnosis of sialorrhea. Methods
Study design and study population This cross-sectional study was carried out at the Saliva Management Clinic, a joint project of the Mackay Rehabilitation Center and the Montreal Children’s Hospital, Canada. The Saliva Management Clinic is a multidisciplinary clinic staffed by an otolaryngologist, a pediatric dentist, an occupational therapist, a speech language therapist, and a social worker22. This study received ethical approval from the institution involved. Informed consent was obtained from the adult responsible for each child participating in the study. Neurologically impaired children with a medical diagnosis of sialorrhea who presented at the Saliva Management Clinic between July 2012 and December 2013 were consecutively included in this study. Children who had received at least one previous OBTXA injection composed the OBTXA group. The control group consisted of children followed by the saliva clinic where OBTXA treatment
was not recommended. The initial eligibility criteria of the OBTXA group were as follows: (i) patients under OBTXA treatment with at least one injection; (ii) patients with elapsed time since last food intake higher than 1 h; and (iii) patients aged from 4 to 18 years. The inclusion criteria of the control group were as follows: (i) patients without previous sialorrhea treatment (including anticholinergic drugs and surgical removal of the salivary glands); (ii) patients with elapsed time since last food intake higher than 1 h; and (iii) patients aged from 4 to 18 years. Children with non-collaborative behavior during saliva collection and clinical oral examination were excluded. Questionnaire. A standardized questionnaire was used to collect participants’ demographic information and dietary habits. Information on dietary intake was obtained using a 24-h dietary recall method. Parents or caregivers were asked in a face-to-face interview about a typical day of the child’s eating and drinking habits. The diet recall form was marked in amount and frequency of (i) sugary drinks, (ii) carbonated soft drinks, (iii) juices, (iv) milk and (v) sugary foods. The consistency of the diet was also undertaken and classified as liquid, pureed, or solid according to the dietary report of foods that were most often consumed by the children. Diet was dichotomized into cariogenic (score ≥5) and non-cariogenic (score
Association of onabotulinum toxin A treatment with salivary pH and dental caries of neurologically impaired children with sialorrhea BEATRIZ FERRAZ DOS SANTOS1, BASMA DABBAGH1, SAM J DANIEL2 & STEPHANE SCHWARTZ1 1 2
Division of Dentistry, Department of Pediatric Surgery, Montreal Children’s Hospital, Montreal, Quebec, Canada, and Department of Otolaryngology, Head and Neck Surgery, Montreal Children’s Hospital, Montreal, Quebec, Canada
International Journal of Paediatric Dentistry 2016; 26: 45–51 Background. Sialorrhea is a common manifesta-
tion of several neurological disorders. The use of intraglandular onabotulinum toxin A (OBTXA) injection has been recognized to effectively treat sialorrhea. As OBTXA injection reduces salivary flow rate and alters salivary quality, its use may have a detrimental effect on oral health. Aim. To examine the effect of OBTXA injection on caries experience and salivary pH of neurologically impaired children with sialorrhea. Design. Twenty-five children receiving OBTXA treatment and 25 control children were enrolled in the study. Whole saliva was collected to determine salivary pH. All participants underwent an interview on their dietary habits. Dental clinical
Introduction
Sialorrhea or drooling is a common and disabling manifestation of several neurological disorders. It is usually caused by a lack of oral-motor coordination, which leads to saliva accumulation in the mouth. Chronic sialorrhea impacts the quality of life of children by causing clinical and functional complications such as aspiration, oral and perioral infections and skin irritation. Additionally, it can cause impairment in social function and increase the burden of care for caregivers1. The prevalence of moderate to severe sialorrhea in developmentally disabled individuals is estimated at 10–37%2. Correspondence to: Dr Beatriz Ferraz dos Santos, Department of Dental Surgery, Montreal Children’s Hospital, 1040 Atwater Avenue, Montreal, QC H3Z 1X3, Canada. Tel: (514) 4124400; Fax: (514) 412-4369. E-mail: [email protected]
examinations were carried out to evaluate caries experience and oral hygiene level. Results. Overall, mean salivary pH value was significantly lower in the OBTXA group (6.92 0.77) compared with the control group (7.36 0.70). Caries activity was significantly higher in the OBTXA group (P = 0.01). The regression analyses showed a significant association between OBTXA treatment and salivary pH value (P = 0.03). Results from the logistic regression show that dental caries was significantly associated with OBTXA treatment (OR = 1.73, CI = 1.14–27.3). Conclusions. The study showed an intricate relationship between OBTXA treatment and oral findings. Hence, special dental care should be given to children receiving OBTXA treatment.
Many approaches have been used to reduce the amount of drooling. Among them, the use of onabotulinum toxin A (OBTXA) injection into the salivary glands has been recognized as one of the most effective and less invasive treatment3–7. Botulinum toxins are thought to reduce saliva production by inhibiting post-ganglionic acetylcholine release8 leading to a reduction in salivary flow rate9–11 and an alteration of salivary quality12. The effectiveness of OBTXA injection to reduce drooling has been widely published, but there is a paucity of knowledge concerning its effect on oral health. Nevertheless, it is well known that saliva plays an important role in the maintenance of good oral health. Saliva protects the oral mucosa against mechanical damage, helps the balance of the remineralization and demineralization process of the enamel, and has defense functions against pathogenic microorganisms13,14. Saliva
© 2015 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
45
46
B. Ferraz dos Santos et al.
also acts as a modulator of salivary pH maintaining its values near neutrality (6.7–7.3)15. The major functions of saliva are directly related to its composition and quantity. Saliva contains 99% water and a wide spectrum of proteins, nucleic acids, electrolytes, and hormones13,16. The concentration of these components varies according to the salivary flow17. Generally, a slight decrease in the salivary secretion rate leads to a decrease in sodium, bicarbonate and pH18,19. Lower salivary pH favors the proliferation of cariogenic bacteria by altering the chemical balance of the tooth surface and increasing the solubility of hydroxyapatite18,20. A reduced salivary flow also compromises the removal of food debris in the mouth21. Therefore, a reduction in salivary rate and pH may lead to an increase in caries activity. The aim of this study was to examine the effect of OBTXA injection on caries experience and salivary pH of neurologically impaired children with a medical diagnosis of sialorrhea. Methods
Study design and study population This cross-sectional study was carried out at the Saliva Management Clinic, a joint project of the Mackay Rehabilitation Center and the Montreal Children’s Hospital, Canada. The Saliva Management Clinic is a multidisciplinary clinic staffed by an otolaryngologist, a pediatric dentist, an occupational therapist, a speech language therapist, and a social worker22. This study received ethical approval from the institution involved. Informed consent was obtained from the adult responsible for each child participating in the study. Neurologically impaired children with a medical diagnosis of sialorrhea who presented at the Saliva Management Clinic between July 2012 and December 2013 were consecutively included in this study. Children who had received at least one previous OBTXA injection composed the OBTXA group. The control group consisted of children followed by the saliva clinic where OBTXA treatment
was not recommended. The initial eligibility criteria of the OBTXA group were as follows: (i) patients under OBTXA treatment with at least one injection; (ii) patients with elapsed time since last food intake higher than 1 h; and (iii) patients aged from 4 to 18 years. The inclusion criteria of the control group were as follows: (i) patients without previous sialorrhea treatment (including anticholinergic drugs and surgical removal of the salivary glands); (ii) patients with elapsed time since last food intake higher than 1 h; and (iii) patients aged from 4 to 18 years. Children with non-collaborative behavior during saliva collection and clinical oral examination were excluded. Questionnaire. A standardized questionnaire was used to collect participants’ demographic information and dietary habits. Information on dietary intake was obtained using a 24-h dietary recall method. Parents or caregivers were asked in a face-to-face interview about a typical day of the child’s eating and drinking habits. The diet recall form was marked in amount and frequency of (i) sugary drinks, (ii) carbonated soft drinks, (iii) juices, (iv) milk and (v) sugary foods. The consistency of the diet was also undertaken and classified as liquid, pureed, or solid according to the dietary report of foods that were most often consumed by the children. Diet was dichotomized into cariogenic (score ≥5) and non-cariogenic (score
