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Assessment and Management
The first step in dealing with drooling is to adequately investigate and describe the nature of the problem. An adequate assessment should explore the cause, severity and contributing factors of the problem in order for an appropriate management plan to be implemented.
Observation of Saliva Control Checklist (Word 60 KB).
This checklist may be of use to parents and professionals. If you are concerned about drooling, complete the checklist and take it to your Speech Pathologist or health care professional for further discussion. This checklist is designed for children who drool but may also be useful for adults.
If you have concerns regarding saliva control contact your local GP or Speech Pathologist and they will refer you to a specialist clinic if necessary.
A specialist clinic in Melbourne, Australia is the Royal Children's Hospital Saliva Control Clinic- The Saliva Control Clinic assesses and advises on treatment and management for children and adolescents for whom drooling is a problem. They provide advice to the family and referring speech pathologist and may also refer to other disciplines and community agencies. The team consists of a Paediatrician, Plastic surgeon, Speech pathologist and Dentist who will have a meeting with the child and his/her family.
For more information view the Saliva control in children booklet published by the Royal Children's Hospital.
After assessment of the drooling has been conducted, an appropriate management program will be implemented. Any treatment which reduces the amount of drooling must also consider the several important functions of saliva. Treatment of saliva control must aim to cause minimal disruption to the primary functions of saliva.
- Eating and drinking skills
- Positioning
- Oral-facial facilitation - Icing, Brushing, Vibration, Manipulation, Oral-motor sensory exercises
- Behavioural approaches
- Appliances
- Oral Hygiene
- Medication
- Botox Injections
- Surgery
Eating And Drinking Skills
Since drooling is often linked with poor eating and drinking skills, treatment may include a special focus on developing skills such as: swallowing, keeping lips closed, using the tongue to gather food etc.
Treatment may also involve ascertaining if there are foods that may be contributing to a drooling problem. For example, acidic fruit drinks or alcohol may need to be cut out of a diet (these may stimulate saliva production) (Johnson & Scott, 1993).
Positioning
Prior to the implementation of any management strategy it is essential that the individual receiving therapy is appropriately positioned.
When seated the person should be fully supported and comfortable. Poor posture can contribute to the drooling problem if the person has reduced head control. Head control provides the basis for developing oral control for swallowing and control of drooling. Work with head and trunk control is appropriate to consider for every person who drools, but critical for individual's who have a physical disability.
Oral-Facial Facilitation
The aim of this technique is to improve oral function therefore increasing the ability to control saliva.
Oral-facial facilitation is a technique which attempts to improve oral-motor control, frequency of swallowing and sensory awareness. Oral-facial facilitation techniques have been used to improve control of saliva with people who have hypertonic (high tone) and hypotonic (low tone) muscles. (Scott & Staios, 1993)
Once the individual is in a stable and comfortable position, one (or a combination) of the following can be tried:
- Icing
- Brushing
- Vibration
- Manipulation
- Oral-motor sensory exercises
Do not attempt any of these techniques without supervision or instruction from a Speech Pathologist.
It has been shown that with some people oral-facial facilitation techniques can be effective in reducing but not eliminating drooling.
Icing
Icing is a procedure which aims to normalise muscle tone in some individuals, thereby improving oral-motor function and enhancing sensory awareness. It involves the application of ice directly over the target muscle.
To maximise the effectiveness of this procedure, an oral activity such as eating or exercise should directly follow icing. The effects of icing are immediate and may last between 5 and 30 minutes.
It has been found that ice helps to stimulate a delayed or absent swallow reflex.
This technique may not always be effective and considerations need to be taken into account. (Scott & Staios, 1993)
Brushing
This technique is also reported to normalise tone and increase sensory awareness. This technique involves using a brush to stroke the muscle in the direction of muscle movement.
The effects of brushing are said to occur 20 to 30 minutes after the procedure. Brushing should take place half an hour before a meal, or half an hour before an oral activity/exercise. (Scott & Staios, 1993)
Vibration
Vibration aims to increase the awareness of the position of the muscles and facilitate more normal tone.
This technique has clinically been found to be more effective than brushing. This is perhaps due to more intense stimulation. This technique involves applying vibration directly to the target muscles in the direction of the movement for approximately 6 to 10 seconds.
The vibration technique is considered not only to be effective for stimulating hypotonic (low tone) muscles, it has also been found useful for those with hypertonic (high) muscles. (Scott & Staios, 1993)
Manipulation
Manipulation techniques such as tapping, stroking and patting are applied directly to the muscles, using fingertips only. This technique involves applying firm even pressure. A quick stretch along the muscle fibers may be useful for stimulating hypotonic muscles. Manipulation procedures are useful not only for their direct effect on facilitating normal movement patterns but also for improving oral function through increased oral awareness and discrimination. (Scott & Staios, 1993)
Oral-Motor Sensory Exercises
The following are suggested exercises that may be incorporated into an individual's program to improve oral-motor function, with the ultimate aim of improving saliva control.
These exercises should immediately follow oral-facial facilitation techniques.
Lip Exercises:
- Make faces in mirror making various shapes with lips (for example, smiling, pursing etc)
- Hold spatula or piece of paper between lips
- Use a wide-diameter straw to suck up thickened fluids (for example, pureed apple) and blow items such as paper and cotton wool.
- Place foods such as jam or peanut butter on the top lip and encourage removal with the bottom lip.
Tongue exercises:
- Attempt to lick lips.
- Try to touch the teeth with your tongue.
- Try and make the tip of your tongue touch the nose.
- Encourage the person to lick envelopes, stickers, lollipops and so on.
Swallowing:
- Encourage the person to attempt to close the lips at the start of the swallow.
- Place subtle visual cues around the environment to remind the person to swallow their saliva.
- Remind the person to keep their head up.
Behavioural Approaches
A behavioural learning program may be suitable for some children or adults. It is designed to remove or introduce particular behaviours for the purpose of reducing drooling. A behavioural learning program is based on learning theory. Behaviours that may be encouraged are swallowing behaviours (eg. lip closure) or regular wiping of the chin. Examples of behaviours that would need to be discouraged are decreasing open-mouth behaviour or reducing hand sucking.
Involvement in a behavioural learning program requires that all people involved in the person's health improvement are fully committed to the program. The planning of the program may involve a team of people who know the person well such as teachers, a parent, friend or siblings. There must be at least one person who can spend time with the person every day who will administer the program consistently.
Behaviours can be rewarded with verbal rewards "well done!" or objects or events such as tokens, money, TV time etc.
For more information, an assessment for potential participation in a behavioural learning program or a referral, contact a local Speech Pathologist.
Appliances
Abnormal muscle tone and movement of the tongue, lips and cheeks can sometimes result in structural changes and difficulty attaining functional oral movements, such as lip closure, voluntary tongue movement, chewing and swallowing.
Various orthodontic appliances have been developed in an attempt to modify and improve oral motor function. These appliances vary in methods of attachment within the mouth and in the length of time they remain in the mouth.
All of these devices need a dentist or suitably qualified personnel to ensure the appliances fit correctly. Regular checks of the mouth and appliance also mean that the family, caregiver and person using the appliance will need to visit the dentist regularly.
When an oral appliance for the purpose of saliva control is contemplated, the following considerations need to be addressed:
- The person's ability to retain the appliance securely may vary due to: Dentition; Oral muscle tone; Sensation in the mouth; Cooperation; Comfort
- The person's motivation and ability to comply with the program.
- The availability of regular support and review by appropriate dental/orthodontic staff.
- The person's physiological and behavioural ability to tolerate the appliance.
Medication
Medications may be prescribed to reduce the amount of saliva and therefore help to control drooling. Benzhexol hydrochloride is a short acting prescribed medication widely used to reduce drooling problems.
This medication works by blocking the release of acetylcholine from nerve endings. Side effects from this medication are uncommon but are possible. Possible side effects may include drowsiness or constipation. Other side effects from this medication should be discussed with your doctor.
Other drugs for controlling excess saliva are also available through your doctor.
Botox Injections
'Botulinum Toxin' (Botox) is a drug that blocks the transmission of nerve impulses to muscles, sweat glands and salivary glands. The procedure consists of botulinum toxin being injected into the salivary glands.
The use of this drug in the reduction of saliva, is a new and emerging procedure currently being investigated at the Royal Children's Hospital, Melbourne Australia.
Surgery For Saliva Control
In some instances the best management solution may be surgery. Surgery for saliva control has been available for some years.
The surgery that is currently carried out in Melbourne, aims to redirect the saliva from sitting at the front of the mouth to going back down the throat.
Saliva control surgery is a procedure which relocates the submandibular ducts to the back of the throat. The submandibular ducts are threaded back under the tongue so that the ducts become repositioned into the back of the throat (the tonsillar area). Thus they can continue to produce saliva which drips down the back of the throat instead of into the front of the mouth.
The sublingual glands are removed to prevent the development of cysts (ranula) in the floor of the mouth as well as improving the consistency of saliva.
The operation lasts for approximately and hour and requires a general anesthetic. The procedure requires a stay in hospital of approximately 3 days.
Surgical complications are uncommon. Possible early complications which may occur with any operation include bleeding, swelling or infection.
Good oral care with regular dental check ups (every 6 months) is very important after the surgery. Saliva is protective for teeth and moving it to the back of the mouth puts the front teeth in danger of developing cavities (decay).
A study published by the Birmingham Children's Hospital reports an overall improvement in drooling in 87% of cases studied following this procedure.
If you are interested in obtaining more information regarding this surgery consult with your local GP.
