Sialorrhea: a Management Challenge NEIL G

Sialorrhea: A Management Challenge NEIL G. HOCKSTEIN, M.D., University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania DANIEL S. SAMADI, M.D., Hackensack, New Jersey KRISTIN GENDRON, M.D., University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania STEVEN D. HANDLER, M.D., University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Sialorrhea (drooling or excessive salivation) is a common problem in neurologically impaired children (i.e., those with mental retardation or cerebral palsy) and in adults who have Parkinson’s disease or have had a stroke. It is most commonly caused by poor oral and facial muscle control. Contributing factors may include hypersecretion of saliva, dental malocclusion, postural problems, and an inability to recognize salivary spill. Sialorrhea causes a range of physical and psychosocial complications, including perioral chapping, dehydration, odor, and social stigmatization, that can be devastating for patients and their families. Treatment of sialorrhea is best managed by a clinical team that includes primary health care providers, speech pathologists, occupational therapists, dentists, orthodontists, neurologists, and otolaryngologists. Treatment options range from conservative (i.e., observation, postural changes, biofeedback) to more aggressive measures such as medication, radiation, and surgical therapy. Anticholinergic medications, such as glycopyrrolate and scopolamine, are effective in reducing drooling, but their use may be limited by side effects. The injection of botulinum toxin type A into the parotid and submandibular glands is safe and effective in controlling drooling, but the effects fade in several months, and repeat injections are necessary. Surgical intervention, including salivary gland excision, salivary duct ligation, and duct rerouting, provides the most effective and permanent treatment of significant sialorrhea and can greatly improve the quality of life of patients and their families or caregivers. (Am Fam Physician 2004;69:2628-34. Copyright© 2004 American Academy of Family Physicians.) aliva is secreted by the six major medulla, and synapse in the otic and subman- salivary glands (two parotid, two dibular ganglia. Postganglionic fibers from the submandibular, and two sublingual) otic ganglion provide secretory function to the and several hundred minor salivary parotid gland, and fibers from the submandibu- glands. The major salivary glands lar ganglion supply secretory function to the Sproduce 90 percent of the approximately 1.5 submandibular and sublingual glands. The flow L of saliva that are secreted per day. In the of saliva is enhanced by sympathetic innervation, unstimulated (basal) state, 70 percent of saliva which promotes contraction of muscle fibers is secreted by the submandibular and sublingual around the salivary ducts. glands. When stimulated, salivary flow increases Sialorrhea (drooling or excessive salivation) by five times, with the parotid glands providing is defined as saliva beyond the margin of the lip. the preponderance of the saliva.1 This condition is normal in infants but usually The various functions of saliva include stops by 15 to 18 months of age. Sialorrhea mechanical cleansing of the mouth, contribut- after four years of age generally is considered ing to oral homeostasis, and helping to regulate to be pathologic. oral pH. Saliva also has bacteriostatic and bac- Physical and psychosocial complications of teriocidal properties that contribute to dental sialorrhea range from mild and inconvenient health and decrease oral odor. It is important in symptoms to severe problems that can have a the lubrication of food boluses, and the amylase significant negative impact on quality of life. in saliva begins the digestion of starches. Physical complications include perioral chap- The parasympathetic nervous system inner- ping and maceration with secondary infection, vates the parotid, submandibular, and sublingual dehydration, and foul odor. The psychosocial glands with fibers that originate in the pons and complications include isolation, barriers to edu- Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2004 American Academy of Family Physicians. For the pri- vate, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or cation (such as an inability to share books or computer keyboards), and increased dependency Sialorrhea usually is caused by neuromuscular dysfunction, and level of care. Caretakers and loved ones hypersecretion, sensory dysfunction, or anatomic (motor) dys- may find it more difficult to demonstrate affec- function. tion with affected patients, contributing to a potentially devastating stigmatization. Etiology reflux, toxin exposure (i.e., mercury vapor), and Sialorrhea usually is caused by neuromuscu- rabies. lar dysfunction, hypersecretion, sensory dys- Under normal circumstances, persons are function, or anatomic (motor) dysfunction. The able to compensate for increased salivation by most common cause is neuromuscular dysfunc- swallowing. However, sensory dysfunction may tion. In children, mental retardation and cere- decrease a person’s ability to recognize drooling, bral palsy are commonly implicated; in adults, and anatomic or motor dysfunction may impede Parkinson’s disease is the most common etiology. the ability to manage increased secretions. Pseudobulbar palsy, bulbar palsy, and stroke are Anatomic abnormalities are usually not the less common causes (Table 1). sole cause of drooling but commonly exacer- Hypersecretion commonly is caused by inflam- bate other causative conditions. Macroglossia mation, such as teething, dental caries, and oral (enlarged tongue) and oral incompetence may pre- cavity infection. Other causes of hypersecretion dispose patients to salivary spill. Unfortunately, include side effects from medications (i.e., tran- neither of these conditions is easily remedied. quilizers, anticonvulsants), gastroesophageal Malocclusion and other orthodontic problems may compound oral incompetence; orthodontic TABLE 1 correction can reduce sialorrhea. Etiology of Sialorrhea Surgical defects following major head and neck resection and reconstruction also may Neuromuscular/sensory dysfunction cause sialorrhea. The most notable example of Mental retardation these anatomic defects is“Andy Gump” deformity, Cerebral palsy which is caused by the loss of the anterior man- Parkinson’s disease dibular arch (Figure 1). Pseudobulbar* Bulbar palsy* Assessment of Sialorrhea Stroke* Objective and subjective measures have been Hypersecretion† developed to quantify sialorrhea. The objective Inflammation (teething, dental caries, oral-cavity infection, rabies) tests using radioisotope scanning and collec- Medication side effects (tranquilizers, tion cups strapped to the patient’s chin are anticonvulsants) Gastroesophageal reflux Toxin exposure (mercury vapor) Anatomic‡ Macroglossia (enlarged tongue) Oral incompetence Dental malocclusion Orthodontic problems Head and neck surgical defects (i.e., “Andy Gump”deformity) *—Less common. Usually controlled by increased swallowing. †— FIGURE 1. “Andy Gump” deformity. This anatomic Frequently exacerbate existing problems. ‡— defect results from resection of the anterior man- dibular arch without adequate reconstruction. JUNE 1, 2004 / VOLUME 69, NUMBER 11 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-2629 TABLE 2 malocclusion. Otolaryngologists identify and System for Assessment of correct causes of aerodigestive obstruction like Frequency and Severity of Drooling macroglossia and adenotonsillar hypertrophy that contribute to drooling. Neurologists, oto- Drooling Points laryngologists, and primary care physicians can Severity assess the patient for significant cranial neu- Dry (never drools) 1 ropathies. Mild (wet lips only) 2 After a thorough assessment, a consensus on Moderate (wet lips and chin) 3 appropriate treatment options should be devel- Severe (clothing becomes damp) 4 oped by the treatment team, the patient, and the Profuse (clothing, hands, tray, 5 patient’s family. Treatments can be offered in a objects become wet) stepwise fashion, from least invasive, nonsurgi- Frequency cal therapies to most invasive. Never drools 1 For minimal problems, in children under four Occasionally drools 2 Frequently drools 3 years of age, or in adults with unstable neuro- Constantly drools 4 logic function, observation is frequently the best option.4 Minimal problems also can be Information from Thomas-Stonell N, Greenberg J. treated with a feeding program aimed at improv- Three treatment approaches and clinical factors in the ing oromotor control, although this effort is reduction of drooling. Dysphagia 1988;3:75. rarely successful. Any situational factors should be corrected, and dental malocclusion and caries should be treated. Adenotonsillectomy should be per- formed, when indicated, and patients should be used primarily for research purposes. A variety fitted with appropriate wheelchairs and braces, of subjective scales for sialorrhea have been if necessary. described.2 One system rates the severity of Several orthodontic appliances may be used drooling on a five-point scale and the frequency for the treatment of sialorrhea. Customized of drooling on a four-point scale (Table 2).3 plates formed to fit the palate can aid in better Although scales are useful in assessing and lip closure.5,6 Movable beads can be placed on monitoring

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