Case Studies

Drooling - Scenario
Dry Mouth - Scenario

Drooling - Scenario

"Tracey" is a 10-year-old girl who has cerebral palsy. She uses a wheel chair to get around and does control it herself with a hand switch, though her fine motor skills are not so good. Tracey does not speak clearly, and drools a lot. Her communication aids get very wet, and her mother finds she has to change Tracey's clothes at least twice a day. People sometimes stare at Tracey and her mother doesn't want to add to this by putting a bib around Tracey's neck. Tracey has had several visits to the doctor because her mum is concerned about her oral hygiene. The doctor just gives her cream to sooth sores that develop and tells her that nothing else can be done- her cerebral palsy is the cause for her drooling and that cannot be cured.

What can be done for Tracey and her mother?

It is important for both Tracey and her mother to attend an initial assessment with a speech pathologist. Further sessions may later be recommended or a home program developed. The speech pathologist may recommend several management strategies for Tracey as well as providing informational counselling to Tracey and her mother. Initially, an assessment would be conducted to identify the nature and severity of the drooling. Several steps can then be taken in an attempt to improve the drooling. A daily behavioural learning program could be suitable for Tracey. This would require either Tracey's mother or other family member, friend or someone at Tracey's school to commit time to implementing management techniques into Tracey's daily routine.

The Speech pathologist may attempt some oral-facial facilitation, eg. working on head and neck positioning, tongue and lip control and strengthening. Sensory stimulation of her lips or cheeks could also be attempted eg using vibration to stimulate the muscles around her mouth.

Tracey may be a suitable candidate for the implementation of an intraoral appliance. See 'Drooling- Management- Appliances' section for further details.

The speech pathologist can also provide compensatory strategies, such as wearing a section of towelling on her clothes rather than a bib to avoid social awkwardness. This may improve the social impact that the drooling is having on Tracey and her mother. See 'Drooling- Management' section for further details.

Maintaining good oral hygiene will be important for eliminating the chance of caries due to saliva loss- such as regular brushing and flossing.

If these attempts have little or no improvement, a referral to a specialist clinic (such as the RCH- Saliva Control Clinic, Melbourne Australia) may be necessary. If necessary, they may prescribe medication or perhaps surgery as a means of improving the drooling.

Dry Mouth - Scenario

"Mike" is a 54-year-old truck driver who has been a heavy smoker and social drinker for the past 32 years. He has recently been diagnosed with prostate cancer. Mike began his first period of chemotherapy 2 weeks ago, and now finds that along with hair loss and nausea, his mouth often feels dry and the saliva in his mouth is very thick and ropey. Mike also has difficulty sleeping, his mouth feels just so uncomfortable, but he puts the insomnia down to the large amounts of coffee he drinks to keep himself awake on the roads. He also continues to smoke and drink as he believes they are not the cause of his cancer, so why should he stop now?

What can be done for Mike's dry mouth?

After complaining about his dry mouth at his next chemotherapy treatment session, Mike was referred to a Speech Pathologist by the clinical nurse specialist who oversees his treatment. After talking to Mike and investigating all possibilities, the speech pathologist concluded that Mike's dry mouth is most likely a secondary symptom from his chemotherapy. Therefore, as chemotherapy cannot be stopped, it will be important for Mike to treat the symptoms of dry mouth to relieve the discomfort he is experiencing. There are several behavioural treatments that Mike can begin:

• Sip water frequently throughout the day, and in particular, keep a drink on his bedside table to sip throughout the night.
• Use specially designed products which help to lubricate the mouth, such as Biotene mouth spray during the day and Biotene moisturising gel at night (the effects of the gel are longer lasting so more suited to night-time use).
• Sleep on his side to reduce mouth breathing.
• Use a humidifier during the night, as the water droplets in the air ensure constant lubrication of the mouth and throat when breathed in.
• Chew sugar free gum. Not only does the chewing stimulate the flow of saliva, but by being sugar free it doesn't add to the difficulties Mike may experience with dental hygiene as a result of the dry mouth.
• Include plenty of sauces or gravies with meals as this lubricates the food to ensure comfort while eating.

For more information, see General Behavioural or Palliative Treatments.

There were also some substances that Mike should attempt to avoid, as they have drying effects on the mouth. In particular for Mike the alcohol, smoking and coffee were a problem. Mike did not realise that these contributed to the discomfort he was experiencing and so vowed to stop the smoking and alcohol, and drink tea instead, cutting down to three cups a day. Though tea contains caffeine and also has a drying effect on the mouth, Mike and his speech pathologist both agreed that he should not have to sacrifice everything he enjoys in life.

It was also recommended to Mike that he make regular appointments with his dentist whilst undergoing his chemotherapy. A lack of saliva can result in impaired oral hygiene, causing dental caries and lesions in the mouth, and the dentist would have the expert knowledge to advise on appropriate care for Mike's mouth, and provide treatment if required. For general guidelines on oral hygiene see Maintaining Good Oral Hygiene.