Sialorrhea or drooling as is commonly known refers to pooling of saliva in the mouth. It occurs around 50-80% of all Parkinson’s patients particularly in men. The excess saliva then begins to literally spew out because of difficulty swallowing. Normally we produce about a liter of saliva a day which helps us break down food and keep our mouths moist and protect against bacterial infections in the gums. Ordinarily, we swallow such quantities without giving it a second thought. However, as Parkinson’s disease advances and our swallowing muscles become stiffer and slower it is sometimes difficult to keep up with the enormous production and some of it unfortunately ends up around the outside of our mouths or spilling unto our clothing causing great social embarrassment. But also because it lingers in the corners of our mouths it can cause sores and tissue break down as well as give us halitosis (bad -stale breath). Worst if we develop a large amount of pooling of saliva we can accidentally swallow a big bolus or gulp in to the lungs causing “aspiration pneumonia” landing patients inadvertently into the hospital.
Therefore, it is extremely important that if you are experiencing excessive saliva or drooling that you discuss with your physician immediately to avoid aspiration, anxiety, or social embarrassment. You no longer have to be ashamed or self conscious in public while eating, talking or going out because you have to carry around a try or feminine pad as several of my patients have done in desperation in an attempt to collect all the excess saliva.
This dramatic sight ingrained in my brain permanently is the reason why I write about this so no one has to suffer this type of humiliation any further.
Here are some helpful tips & treatments options to help with this pesky and often overlooked problem in hopes of returning patients to a normal life.
1) First and foremost, there needs to be a medication adjustment – typically an increase of medication (levodopa or dopa agonists) to improve stiffness and slowness of muscles involved in swallowing including tongue, lips etc.
2) speech therapy to strengthen muscles around the lips and also swallowing should also be instituted concomitantly particularly to avoid aspiration.
3) physical/ occupational therapy along with increase medications should also be considered to improve posture because the tendency to stoop forward with head forward and chin outward (typical Parkinson’s stance) causes pooling of saliva to front of mouth along with the help of gravity easier. The team of expert therapist will help instruct on proper sitting techniques as well as cues to-try to keep head up so that saliva naturally drains to the back. Sitting upright also helps saliva go down so once again cues can be thought to remember to do this at all times.
4) medications like Levsin may help to reduce drooling. However, these may not be used if severe constipation or extremely slow gut motility is present.
5) Tricyclics medications (e.g. Elavil) because of its side effects especially tendency to dry mouth are sometimes good starts and frequently used but these have to be used with caution because in the elderly or those that have problems with orthostatic hypotension, severe constipation this class of medication can make things worse for those people.
6) extremely important is to review medication list with your physician because some medications are known to cause increase salivation like some antipsychotics such as Clozapine.
7) keep hard candy in mouth (sucking it) sugar free preferably to avoid cavities and also because sugary foods increase production of saliva. Therefore, minimize sugary types of foods. If you must have chocolate try sugar free- Godiva has some excellent choices! You may also suck on ice chips to decrease drooling.
8) drink fluids more frequently to “wash down” saliva; preferably drink water which will also help decrease constipation.
9) do lip exercises to improve lip seal and prevent saliva dripping out – hold a wide smile (bet you makes you feel better too!) then pucker lips like you are going to blow a kiss or whistle- do these several times a day. Or suck from straw when you drink.
10) Anticholinergic drugs (e.g. Artane or antihistamines) may also be use. However, not everyone is able to use these because of cognitive problems it can cause so if someone is already. confused, forgetful or hallucinating this will not be a good choice.
****Best remedy I have found however is injection of Botox into salivary gland …this is local treatment with little or no side effects especially systemic ( will not interfere with other medications) and duration of Botox last anywhere from 3-6 months sometimes longer. Now, fortunately we have different types of botulinum toxin so you have many choices. In past, with severe cases there have been reports of radiation to salivary glands to make less effective or surgically removing salivary glands. But, I don’t commend these drastic techniques with all the other treatments unless everything has failed and drooling extremely severe causing aspiration especially in light of fact that we need saliva to aid in digestion, lubrication of our mouths and throat and prevent plaque buildup. If our mouths become too dry (Xerostomia) as I mentioned in another blog this can lead to severe pain (‘burning mouth syndrome’). I have had excellent results with Botox injections over the years without need for more drastic measures. *******
Finally, brush your teeth regularly after each meal to reduce probability of infection that may set in due to stagnant saliva.
Nevertheless, all of these treatments are subject to your own physicians discretion and do not recommend making any alterations to your medicines without first discussing with your doctor or healthcare provider.
FYI -20% of PD patients also experience post nasal drip (dripping of mucous into throat) worst at night causing cough, sneezing, and interfering with sleep. By drying out mucous with these medications and remedies this problem most likely will be resolved as well. Sometimes your doctor may prescribe a decongestant as well.
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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network).
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