What Are The Options for Treating Excessive Salivation?

Patient Presentation
A 6-year-old female came to clinic for her health supervision visit. She had cerebral palsy and mild mental retardation but was making good progress with appropriate interventions. She continued to have significant drooling that was interfering with her social relationships with peers. Although peers liked her and included her, they did not want to work in small groups or eat lunch next to her because of the drooling. Glycopyrrolate had been tried without success. She was otherwise doing well in school and was able to participate in modified gross motor games and gym activities. The past medical history was signficant for heel cord lengthening and general anesthesia for dental restorations. The pertinent physical exam showed her growth parameters to be in the 10-75%. She was conversant and used ankle-foot orthoses and a walker because of an unsteady gait. HEENT showed excessive salivation and some plaque on her teeth. She had spasticity of all 4 extremities with lower extremities more affected than upper. Her heel cords were tight, but she easily used her orthoses.

The diagnosis of cerebral palsy, mild mental retardation, and excessive salivation causing social impairment was made. The pediatrician told the mother that he knew there were other options but wasn’t sure about all of them. He said that he would investigate and then follow-up. Over the next week, he contacted a developmental pediatrician, a neurologist and did an Internet PubMed search. He sent the parents a letter with the various options he had found. They chose to try cyproheptadine every evening. The patient’s clinical course at one month followup showed the cyproheptadine had improved the drooling significantly and was not causing any side effects.

Discussion
Drooling, excessive salivation, hypersalivation, or sialorrhea can be a big problem for children. It can cause wet clothing necessitating bibs or multiple changes of clothing. It can cause dermatitis of the face, neck and chest, with possible skin breakdown and/or possible secondary infection. Sialorrhea can also potentiate the spread of common infections to others though direct or indirect contact with the saliva. It can also cause impaired social interaction as noted above. Therefore it is a problem that should be taken seriously and treated as necessary.

Sialorrhea is generally considered abnormal if it occurs during the day after the age of 3-4 years. Most people affected have some other neurological problem including cerebral palsy or in adult populations, patients with Parkinson’s disease. Sialorrhea varies minute to minute and day to day. Therefore it is hard to quantify the overall outcome, especially for research purposes.

Learning Point
There are several options for treatment:

  • Do nothing – If the drooling is relatively mild and can be effectively managed by the child and family easily, and the child is not distressed by the drooling and is not having social impairments, this can be a good option.
  • Behavioral modification, speech therapy, with or without intraoral appliances – effectively used to train the patient to improve the stability of the jaw and lip closure. Trained personnel are needed for this option.
  • Medication
    • Anticholinergic agents – these are the most common medication used. Different forms of the medications are available in different countries and therefore there are differences in their utilization. Side effects can include constipation, urinary retention, sleepiness, irritability, and flushing, and generally are expected and reversible.
      • Glycopyrrolate – often used as a first agent with variable results but improvement in 70-90% of patients is reported. However because of side effects, about 30% of patients will choose to discontinue because of side-effects.

      • Scopolamine – also a common agent. Often has more severe side effects than glycopyrrolate.
      • Benztropine – also a common agent.
      • Cyproheptadine – less often used than other anticholinergics for sialorrhea, but often used in children for migraines or appetite enhancement.
    • Anti-reflux agents – as reflux causes excessive salivation, if the reflux is treated then the salivation will decrease. May or not be effective.
    • Trihexyphenidyl – antispasmotic agent used with Parkinson’s patients that also may decrease salivation
  • Botulinum toxin injection – Has been used in children (but mainly with adults) with maximum effect 2-8 weeks after injection. It can have side effects and must be repeated at intervals.
  • Surgery – The specific surgeries vary but often include transection of some innervation to the salivary glands. It can be very effective. However it does require surgery and excessive salivation may still occur and there may be side effects such as facial nerve palsy. The surgeries are generally infrequently performed, so it may be difficult to find an experienced, willing surgeon to perform the operation.

With successful treatment of sialorrhea, the decrease in saliva can pose an increase risk of dental disease. Patient need to have appropriate dental care and utilize fluoride toothpaste to maintain good oral health.

Questions for Further Discussion
1. What health care professionals are available locally to help you manage sialorrhea?
2. What is the definition of cerebral palsy and what are common causes?
3. What are common problems associated with cerebral palsy?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Mouth Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Nunn JH. Drooling: review of the literature and proposals for management. J Oral Rehabil. 2000 Sep;27(9):735-43.

Blasco PA. Management of drooling: 10 years after the Consortium on Drooling, 1990. Dev Med Child Neurol. 2002 Nov;44(11):778-81.

Tscheng DZ. Sialorrhea – therapeutic drug options. Ann Pharmacother. 2002 Nov;36(11):1785-90.

Jongerius PH, van Tiel P, van Limbeek J, Gabreels FJ, Rotteveel JJ. A systematic review for evidence of efficacy of anticholinergic drugs to treat drooling. Arch Dis Child. 2003 Oct;88(10):911-4.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital