Scope - Communication Resource Centre

Saliva Management

Drooling

What is Drooling?
Causes of Drooling
Associated Disorders
Assessment & Referral
Management
References

What Is Drooling?

Drooling is the unintentional loss of saliva from the mouth.

Drooling is a normal phenomenon in children prior to the development of oral muscular control at age 18-24 months. Many children lose control of saliva and drool as they are developing control of gross motor and fine motor movements.

Control of drooling requires developed oral sensation and muscle movements to swallow automatically while focusing attention on new skills. The development of stability is a major component of normal development, and stability of the head, neck and shoulder girdle is prerequisite to fine motor control of the mouth. (Morris & Klein, 2000)

Whilst drooling is a normal occurrence in young children, persistence of drooling beyond four years of age is not considered normal. (Crysdale, 1989) If a child continues to drool beyond four years old it may be a result of very low muscle tone or the child may have a physical disability or developmental delay. Individuals with a disability may have reduced muscle control. When this control is lacking, drooling is likely to occur.

In an Australian study of people with complex communication needs in a variety of diagnostic groups, 29% were found to experience issues relating to saliva control. (Perry, Reilly, Bloomberg & Johnson, 2002)

Inadequate saliva control is seen in between 10% (Ekedahl, 1974) and 37% (Van de Heyning et al, 1980) of children with Cerebral Palsy.

Causes Of Drooling

Drooling can be a result of hypersecretion (increased secretion) of saliva but more commonly occurs as a result of impaired oral muscle control.

Drooling often occurs as a result of a decrease in the frequency of spontaneous swallowing, and/or a reduction in the sensory awareness necessary for the swallowing. (Johnson & Reilly, 1993)

Swallowing

Swallowing occurs when we eat or drink and when we swallow saliva.

The act of swallowing involves a complex and coordinated sequence of movements. Swallowing requires lip closure, jaw stability and controlled tongue movements. There are three stages in the swallowing of food process: the oral phase, pharyngeal phase and oesophageal phase. The phase most relevant to saliva control is the Oral Phase.

Oral Phase

The oral phase occurs in the mouth and is a voluntary process. During the oral phase the food is chewed in the mouth and prepared before it is swallowed. To do this, the person must be able to move the jaw up and down to chew the food. It is also important to be able to bring the lips together in order to keep the food or fluid from spilling out of the mouth. Control of the tongue is also required to clear food from the teeth and assist in preparing the food for swallowing.

The tip of the tongue is then raised and as the tongue contracts, the food or fluid is pushed towards the back of the throat.

This phase also occurs when we swallow saliva. Every few minutes saliva collects in the mouth and provides a pressure cue needed to trigger a swallow. The same process takes place with the tongue contracting and pushing the saliva to the back of the throat.

Swallowing can contribute to drooling if the person does not swallow frequently enough or if the swallowing is not effective. Delayed or limited oral skills can also influence the development of tongue elevation during the swallow.

Disorders Associated with Drooling

Drooling is a common problem among some persons with physical and/or intellectual disabilities.

The following disorders are more commonly associated with drooling.

Cerebral Palsy
Parkinson's Disease
Multiple Sclerosis
Stroke

Cerebral Palsy
Cerebral palsy is a developmental disability that results from damage to or dysfunction of the developing brain. The impairments associated with cerebral palsy are non-progressive but are permanent. The degree of impairment may vary in relation to movement and posture, daily living skills and communication or socialisation skills. Although Cerebral Palsy is a permanent condition, as a person learns and grows and practices skills, more control over movement may be achieved. No two individuals are affected in the same way… some people may have minor motor skill problems, while others may be totally physically dependent.

Inadequate saliva control is seen in between 10% (Ekedahl, 1974) and 37% (Van de Heyning et al, 1980) of children with Cerebral Palsy.

People with Cerebral Palsy may drool because of:

Issues with posture- poor head & neck control
Difficulty in effectiveness or frequency of swallowing
Reduced control of the muscles of the face and mouth
Reduced sensation of the muscles of the face and mouth

For more information on Cerebral Palsy

Parkinson's Disease
Parkinson's disease is a progressively degenerative neurological disorder which affects the control of body movements.

The presentation of symptoms varies greatly between individuals diagnosed and no two people will be affected in the same way.

The three symptoms used for diagnostic purposes are:

Tremor (shaking, trembling, )
Rigidity (stiffness of the muscles)
Bradykinesia (slowness of movement)

At present there is no known cause and therefore the illness is termed; "idiopathic". It is not considered to be genetic although 10% of cases have a familial incidence.

People with Parkinson's Disease may drool because of:

Stiffness of muscles around the face and mouth
Difficulty in effectiveness or frequency of swallowing

For more information on Parkinson's Disease

Multiple Sclerosis (MS)
In MS, the body's immune system attacks its own myelin, causing disruption to the messages sent by the nerves. It is thought that genetic and environmental factors are involved - but the actual trigger to the disease has not yet been discovered.

The symptoms of MS are varied and unpredictable, depending on which part of the central nervous system is affected and to what degree.

MS can cause difficulties in motor control, fatigue, neurological symptoms, continence problems and neuropsychological symptoms.

People with Multiple Sclerosis may have issues with drooling because of:

Reduced control of the muscles of the mouth
Difficulty in effectiveness or frequency of swallowing

For more information on MS

Stroke
A stroke interrupts blood flow to an area of the brain. A stroke occurs when a blood clot blocks a blood vessel or artery, or when a blood vessel breaks. Stroke may also be called a "Brain Attack" or Cerebral Vasular Accident (CVA).

The specific abilities lost or affected depend on where in the brain the stroke occurs and on the size of the stroke (i.e. the extent of brain cell death). For example, someone who has a small stroke may experience only minor effects. On the other hand, someone who has a larger stroke may be left paralysed on one side or in a coma. Some people recover completely from less serious strokes, while other individuals lose their lives to very severe strokes.

People who have had a stroke may drool because of:

Issues with posture- poor head & neck control
Difficulty in effectiveness or frequency of swallowing
Reduced control of the muscles of the face and mouth
Reduced sensation of the muscles of the face and mouth

For more information on Stroke

Assessment

The first step in dealing with drooling is to adequately investigate and describe the nature of the problem. (Johnson & Reilly, 1993) 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

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.

Referral

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.

Contact the Royal Children's Hospital, Melbourne, Australia for more information.

Management

Eating and drinking skills
Positioning
Oral-Facial facilitation
Behavioural approaches
Appliances
Medication
Surgery
Other Tips and Strategies
Resources

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.

Other Tips and Strategies

Despite all the treatments available for drooling, it is at times inevitable that something immediate must be done to counteract the problem. Sometimes, even after treatment- a drooling problem may persist. Here are some practical compensatory tips for when and after a child or adult drools:

Children can wear bibs for the purpose of moppng up the excess saliva, although this may become innappropriate for adults and older children.
Towelling can be attached to clothes (sewn on).
Scarves of absorbant material can be worn for around the neck. A variety of colours may be necessary for coordinating with different outfits.

Resources

This section contains handouts developed by the Royal Children's Hospital, Melbourne, Australia.

Use Of Artane In The Management Of Drooling

Use Of Glycopyrrolate In The Management Of Drooling

Botulinum Toxin In The Management Of Drooling

Surgery For Saliva Control

Drooling Measures Form

Saliva Control Assessment Form

The following handouts contain helpful tips for children with saliva control problems. It is advised that these are only conducted under instruction from your Speech pathologist or health care professional.

"Getting those hands out of the mouth",
pdf format (1 page, 18 KB)
text format(1 page, 3 KB)

"Helping your child towards a dry chin",
pdf format (1 page, 13 KB)
text format(1 page, 3 KB)

"Helping your child to feel the saliva",
pdf format (1 page, 26 KB)
text format(1 page, 3 KB)

"Getting those lips together and working",
pdf format (1 page, 37 KB)
text format(1 page, 2 KB)

"Getting that tongue going",
pdf format (1 page, 16 KB)
text format(1 page, 3 KB)

"Keeping up appearances",
pdf format (1 page,19 KB)
text format(1 page, 2 KB)

References

Crysdale, 1989. in Webb, K., Reddihough, D., Johnson, H., Bennett, C. & Byrt, T. 1995. "Long-Term outcome of saliva control surgery": Developmental Medicine and Child Neurology. (37), 755-762. Ekedahl, C. 1974. "Surgical treatment of drooling" : Acta Oto-Laryngolica; (77), 215-20. Ferguson L. & West D. 1993. A Practical Approach to Saliva Control Communication Skill Builders Inc: Tucson, Arizona Information supplied by: Royal Children's Hospital, Melbourne, Australia 2003 Johnson, H., King, J. & Reddihough D. 2001. "Children with Sialorrhea in the absence of neurological abnormalities" : Child: Care, Health & Development: (27), 591-602 Johnson, H. & Reilly, S. 1993 A Practical Approach to Saliva Control Communication Skill Builders Inc: Tucson, Arizona Johnson, H & Scott, A. 1993. A Practical Approach to Saliva Control Communication Skill Builders Inc: United States of America Mathers, S., Reddihough, D. & Scott A. 1993. A Practical Approach to Saliva Control Communication Skill Builders Inc: United States of America Morris, S. & Klein, M. 2000. Pre-Feeding Skills: A comprehensive resource for feeding development. Therapy Skills Builder, Communication Skill Builders; Tucson, Arizona. Perry, A., Reilly, S., Bloomberg, K. & Johnson, H. 2002. An analysis of needs for people with a disability who have complex communication needs. Faculty of Health Sciences, La Trobe University, Bundoora, Australia. Scott, A.& Staios. 1993. A Practical Approach to Saliva Control. Communication Skill Builders Inc: Tucson, Arizona. Uppal, H., De, R., D'Souza, A., Pearman, K. & Proops, D. 2003. "Bilateral submandibular duct relocation for drooling: an evaluation of results for the Birmingham Children's Hospital": Eur Arch Otorhinolaryngol: (260): 48-51. Van de Heyning, P., Marquet, J. & Creten, W. 1980. "Drooling in children with cerebral palsy" : Acta Oto-Rhino-Laryngolica Belgica; (34), 691-705. Webb, K., Reddihough, D., Johnson, H., Bennett, C. & Byrt, T. 1995. "Long-Term outcome of saliva control surgery.": Developmental Medicine and Child Neurology: (37), 755-762 Parker, A. 2003. "Sialorrhea- The Drooling Patient", Department of Otolaryngology, Loyola University website, retrieved on 12-06-2003 from: www.luhs.org/depts/otolaryn/P_peds.htm. Unlisted author www.scopevic.org.au/info_about_cp.html Last modified 28/08/2003. Retrieved on 14/9/2003 Unlisted author www.Drooling.com. Last modified 2002. Retrieved on 2/6/2003 Unlisted author. MS Australia www.msaustralia.org.au/msinformation.faqs.html#1 Last modified 25/1/2002. Retrieved on 21/7/2003 Unlisted author. National Stroke foundation. www.strokefoundation.com.au/index2.html Created 1/4/2003 Retrieved on 14/5/2003 Unlisted author. Parkinsons Victoria www.parkinsons-vic.org.au Last modified (not listed) Retrieved on 9/7/2003 Unlisted author. The cerebral palsy association of Western Australia Ltd www.cpawa.com.au/cerebral.htm, Last modified (not listed) Retrieved on 14/5/2003 Unlisted author. www.rch.unimelb.edu.au Retrieved on 1/4/2003 Last modified 28/7/2002 Unlisted author. http://www.netally.com/uep/surgical.htm. Retrieved on 2/7/2003. Last modified (not listed)