Drooling quantification: Correlation of different techniques

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Abstract

Objectives

The aim of this study is to evaluate the correlation of the Drooling Quotient (DQ) score with the questionnaire-based Drooling Severity and Frequency Scale (DSFS) and the number of bib changes in a day. It is hypothesized that there is a significant positive correlation between these methods of assessment.

Methods

Using a prospectively collected database from a cohort of one hundred and fifty five children referred to our saliva management clinic, a comparison of the following three measurements was made to assess the level of correlation between them: (1) Drooling Quotient (DQ) (performed in two 10-min sessions), (2) Drooling Severity and Frequency Scale (DSFS) (as judged by parents or caregivers) (3) number of bib changes (as reported by parents or caregivers).

Results

The results showed that there is a high level of agreement between the Drooling Quotient and the Drooling Severity and Frequency Scale. However, the Drooling Quotient and number of bib changes did not show significant correlation.

Conclusions

The Drooling Severity and Frequency Scale (DSFS) has been shown to be a quick and accurate measure of drooling that can be used to help guide clinical management of drooling, particularly in patients who are unable to undergo the Drooling Quotient assessment.

Introduction

Drooling is defined as the presence of saliva beyond the margins of the lip. It is part of normal physical development in newborns and infants, decreasing significantly by eighteen months of age such that by the fourth year, the presence of drooling is considered abnormal. Drooling can become a considerable medical and social problem in children and young adults and it is common in children with neurological and muscular disorders. Drooling arises more as a consequence of an inability or inefficiency of the swallowing rather than from an excessive production of saliva [1].

The treatment options available for managing drooling are tailored to the severity of the problem. Different therapeutic strategies that have been used to reduce or eliminate drooling include behavioral therapy, medication, Botulinum toxin injection, and surgery [1], [2].

A major limitation of many studies on drooling is the absence of standardized quantitative methods to assess the effectiveness of the treatment, and specifically the inadequacy of some methods that attempt to quantify drooling. This makes it difficult to evaluate the effects of different interventions on drooling. It may even impact the conclusions that may be drawn regarding different treatment options. The amount of drooled saliva has been quantified using radioactive isotopes [3]. However, this method was found invasive, cumbersome and problematic [4]. Collection devices have also been used, such as suction bags used as collecting units for saliva. Sochaniwsky et al. [5] introduced a cup-like collection device held against the chin with straps attached on the orthodontic head bonnet; the saliva collected is then suctioned from the cup in to a calibrated test tube where it would be measured. However, the occurrence of leakages makes the measurements inaccurate [5], [6]. Vanderburg et al. reported a subjective method focusing on the effect of a self-management strategy. Here, the duration of dryness (in minutes) is recorded during daily activities [7]. Other approaches that have been used include bib weighing and the use of absorbent cotton dental rolls inserted into the oral cavity. However imprecisions have also been reported with these methods [4].

Over the last decade, the Drooling Quotient (DQ), a semi-quantitative observational method has been used. It is a direct observational objective method that quantifies the number of drooling episodes occurring over two observation sessions [8]. Due to the long period of evaluation, which is needed to obtain an accurate drooling score [4], this method is difficult to perform in patients with severe neuromuscular disease and in patients with severe agitation. Many clinicians have therefore used other methods (often subjective) in addition to the DQ. Questionnaire-based subjective assessment of drooling has been described; this involves the measurement of the severity and frequency of drooling. The Drooling Severity and Frequency Scale (DSFS) [9], is one of such subjective methods whereby parents are asked to rate the severity and frequency of drooling. The weight and number of bib changes per day is another method that can be used to measure drooling [10], [11].

While the addition of subjective methods is beneficial, their validity has been scarcely studied. This uncertainty, and a desire to give clinicians a simpler tool to guide treatment of drooling, has been the rationale for the current research.

Section snippets

Inclusion criteria

(1) The presence of drooling regardless of its severity and frequency. Drooling was defined as a presence of saliva beyond the lower lip margin or a string of saliva falling from the mouth for more than 2 s, (2) four to eighteen years old, (3) diagnosis of mild to moderate neurological disorder Good cooperation allowing for DQ measurement in two 10-min sessions, (4) family communicates in English or French.

Exclusion criteria: (1) absence of drooling, (2) patients less than four years old or more

Results

The results showed that there was a strong association between the subjective DSFS score and the objective DQ scale, as indicated by a high positive Spearman rank correlation coefficient of 0.886 that was significantly different from zero (Fig. 1). There was a somewhat weaker moderate association between the two subjective measures, the DSFS and number of bib changes, having a positive value of 0.335. (Fig. 2) However, there was a weak association between the Drooling Quotient and the Number of

Discussion

Drooling can be assessed objectively using the drooling quotient, which results in a reliable outcome on severity and frequency of drooling [12]. However, it is not feasible in all patients. In addition, drooling severity varies during daily life situations [4]. Subjective measures based on the opinion of the parents or the caregivers such as DSFS and the number of bib changes currently play a significant role in evaluating treatment outcome.

In this study, the positive correlation coefficient

Conclusion

The strong association between the Drooling Severity and Frequency Scale (DSFS) and the drooling quotient (DQ) suggests that the DSFS, which is a quicker and more easily obtained measure of drooling, could be used instead of the DQ to help guide clinical management of drooling in a time constrained-clinical setting. This is particularly important for patients in whom the Drooling Quotient is difficult to obtain.

Conflicts of interest statement

The authors have no conflicts of interest and no financial disclosers.

Acknowledgement

The authors would like to thank Dr. Bernard Segal for reviewing this manuscript.

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