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Sialorrhoea and Drooling in Patients with Parkinson’s Disease

Epidemiology and Management

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Abstract

Although often less recognized than motor symptoms, non-motor effects represent an important source of disability for many parkinsonian patients. Of these non-motor symptoms, sialorrhoea, defined as the inability to control oral secretions resulting in excessive saliva accumulation in the oropharynx, constitutes perhaps one of the most bothersome and troubling problems, often causing social embarrassment and isolation. In patients with Parkinson’s disease (PD), this symptom is thought to be due to restricted swallowing and dysfunction, rather than to hypersecretion of saliva. Only a few well designed studies have been conducted to determine the optimal treatment for sialorrhoea in PD. A combination of approaches appears to be necessary to obtain successful results.

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References

  1. Rascol O, Goetz C, Koller W, et al. Treatment interventions for Parkinson’s disease: an evidence based assessment. Lancet 2002; 359: 1589–98

    Article  PubMed  Google Scholar 

  2. Gulati A, Forbes A, Stegie F, et al. A clinical observational study of the pattern and occurrence of non-motor symptoms in Parkinson’s disease ranging from early to advanced disease [abstract]. Mov Disord 2004; 19Suppl. 9: S406

    Google Scholar 

  3. Visser M, Marinus J, Stiggelbout AM, et al. Assessment of autonomic dysfunction in Parkinson’s disease: the SCOPAAUT. Mov Disord 2004; 19: 1306–12

    Article  PubMed  Google Scholar 

  4. Wüllner U, Schmitz-Hübsch T, Antony G, et al. Autonomic dysfunction in 3414 Parkinson’s disease patients enrolled in the German Network on Parkinson’s Disease (KNP e.V.): the effect of ageing. Eur J Neurol 2007 Dec; 14(12): 1405–8

    Article  PubMed  Google Scholar 

  5. Lal D, Hotaling AJ. Drooling. Curr Opin Otolaryngol Head Neck Surg 2006 Dec; 14(6): 381–6

    Article  PubMed  Google Scholar 

  6. Manor Y, Giladi N, Cohen A, et al. Validation of a swallowing disturbance questionnaire for detecting dysphagia in patients with Parkinson’s disease. Mov Disord 2007; 22: 1917–21

    Article  PubMed  Google Scholar 

  7. Leopold NA, Kagel MC. Prepharyngeal dysphagia in Parkinson’s disease. Dysphagia 1996; 11(1): 14–22

    Article  PubMed  CAS  Google Scholar 

  8. Nagler R, Hershkovich O. Relationships between age, drugs, oral sensorial complaints and salivary profile. Arch Oral Biol 2005; 50(1): 7–16

    Article  PubMed  Google Scholar 

  9. Vissink A, Spijkervet FK, Van Nieuw Amerongen A. Aging and saliva: a review of the literature. Spec Care Dent 1996; 16: 95–103

    Article  CAS  Google Scholar 

  10. Edwards LL, Quigley EM, Pfeiffer RF. Gastrointestinal dysfunction in Parkinson’s disease: frequency and pathophysiology. Neurology 1992; 42: 726–32

    Article  PubMed  CAS  Google Scholar 

  11. Johnston BT, Li Q, Castell JA, et al. Swallowing and esophageal function in Parkinson’s disease. Am J Gastroenterol 1995; 90: 1741–6

    PubMed  CAS  Google Scholar 

  12. Bardow A, Nyvad B, Nauntofte B. Relationships between medication intake, complaints of dry mouth, salivary flow rate and composition, and the rate of tooth demineralization in situ. Arch Oral Biol 2001; 46: 413–23

    Article  PubMed  CAS  Google Scholar 

  13. Friedman A, Potulska A. Quantitative assessment of parkinsonian sialorrhea and results of treatment with botulinum toxin. Parkins Relat Disord 2001; 1: 329–32

    Article  Google Scholar 

  14. Korcyn AD. Autonomic nervous system dysfunction in Parkinson’s disease. In: Calne DB, Crippa D, Trabucchi M, et al., editors. Parkinsonism and aging. New York: Raven Press, 1989: 211–9

    Google Scholar 

  15. Martignoni E, Pacchetti C, Godi L, et al. Autonomic disorders in Parkinson’s disease. J Neural Transm 1995 Suppl. 45: 11–19

    Google Scholar 

  16. Pfeiffer RF, Quigley MM. Gastrointestinal motility problems in patients with Parkinson’s disease. CNS Drugs 1999; 11: 436–48

    Article  Google Scholar 

  17. Edwards LL, Quigley EM, Harned RK, et al. Characterization of swallowing and defecation in Parkinson’s disease. Am J Gastroenterol 1994; 89: 15–25

    PubMed  CAS  Google Scholar 

  18. Bagheri H, Damase-Michel C, Lapeyre-Mestre M, et al. A study of salivary secretion in Parkinson’s disease. Clin Neuropharmacol 1999: 22; 213–215

    PubMed  CAS  Google Scholar 

  19. Bateson MC, Gibberd FB, Wilson RS. Salivary symptoms in Parkinson disease. Arch Neurol 1973; 29(4): 274–5

    Article  PubMed  CAS  Google Scholar 

  20. Ali G, Wallace K, Schwartz R, et al. Mechanisms of oralpharyngeal dysphagia in patients with Parkinson’s disease. Gastroenterology 1996; 110: 383–92

    Article  PubMed  CAS  Google Scholar 

  21. Kalf JG, Smit AM, Bloem BR, et al. Impact of drooling in Parkinson’s disease. J Neurol 2007 Sep; 254(9): 1227–32

    Article  PubMed  Google Scholar 

  22. Chou KL, Evatt M, Hinson V, et al. Sialorrhea in Parkinson’s disease: a review. Mov Disord 2007; 22: 2306–13

    Article  PubMed  Google Scholar 

  23. Bagheri H, Damase-Michel C, Lapeyre-Mestre M, et al. A study of salivary secretion in Parkinson’s disease. Clin Neuropharmacol 1999; 22: 213–5

    PubMed  CAS  Google Scholar 

  24. Parkinson J. An essay on the shaking palsy. J Neuropsychiatry Clin Neurosci 2002; 14: 223–36

    Article  PubMed  Google Scholar 

  25. Edwards LL, Pfeiffer RF, Quigley EM, et al. Gastrointestinal symptoms in Parkinson’s disease. Mov Disord 1991; 6(2): 151–6

    Article  PubMed  CAS  Google Scholar 

  26. Eadie MJ, Tyrer JH. Alimentary disorder in Parkinsonism. Australas Ann Med 1965; 14: 13–22

    PubMed  CAS  Google Scholar 

  27. Edgar WM. Saliva: its secretion, composition and functions. Br Dent J 1992; 172: 305–12

    Article  PubMed  CAS  Google Scholar 

  28. Humphrey SP, Williamson RT. A review of saliva: normal composition, flow, and function. J Prosthet Dent 2001 Feb; 85(2): 162–9

    Article  PubMed  CAS  Google Scholar 

  29. Takayanagi A, Nomura T, Yamanaka S, et al. A modified device for long term sampling of parotid saliva in various experimental conditions. Bull Tokyo Dent Coll 1995; 36: 69–73

    PubMed  CAS  Google Scholar 

  30. Ghezzi EM, Lange LA, Ship JA. Determination of variation of stimulated salivary flow rates. J Dent Res 2000; 79: 1874–8

    Article  PubMed  CAS  Google Scholar 

  31. Dodds WJ. The physiology of swallowing. Dysphagia 1989: 3: 171–8

    Article  PubMed  CAS  Google Scholar 

  32. Rothstein RD. A systematic approach to a patient with dysphagia. Hosp Pract 1997; 32: 169–75

    CAS  Google Scholar 

  33. Ertekin C, Tarlaci S, Aydogdu I, et al. Electrophysiological evaluation of pharyngeal phase of swallowing in patients with Parkinson’s disease. Mov Disord 2002; 17: 942–9

    Article  PubMed  Google Scholar 

  34. Marg S, Walz B, Blenau W. The effects of dopamine receptor agonists and antagonists on the secretory rate of cockroach (Periplaneta americana) salivary glands. J Insect Physiol 2004; 50: 821–30

    Article  PubMed  CAS  Google Scholar 

  35. Koga T, Kobashi M, Mizutani M, et al. Area postrema mediates gastric motor response induced by apomorphine in rats. Brain Res 2003; 960: 122–31

    Article  PubMed  CAS  Google Scholar 

  36. Pazo JH, Belferte JE. Basal ganglia and functions of the autonomic nervous system. Cell Mol Neurobiol 2002; 22: 645–54

    Article  PubMed  CAS  Google Scholar 

  37. Pazo JH, Medina J, Tumilasci O. The role of the caudateputamen nucleus in salivary secretion induced by L-dopa. Neuropharmacology 1982; 21: 261–5

    Article  PubMed  CAS  Google Scholar 

  38. Spivak B, Adlersberg S, Rosen L, et al. Trihexyphenidyl treatment of clozapine-induced hypersalivation. Int Clin Psychopharmacol 1997; 12: 213–5

    Article  PubMed  CAS  Google Scholar 

  39. Penttilä J, Syvälahti E, Hinkka S, et al. The effects of amitriptyline, citalopram and reboxetine on autonomic nervous system: a randomized placebo-controlled study on healthy volunteers. Psychopharmacology (Berl) 2001 Apr; 154(4): 343–9

    Article  Google Scholar 

  40. Crosby N, Deane KH, Clarke CE. Amantadine in Parkinson’s disease. Cochrane Database Syst Rev 2003; (1): CD003468

    Google Scholar 

  41. Proulx M, de Courval FP, Wiseman MA, et al. Salivary production in Parkinson’s disease. Mov Disord 2005; 20: 204–7

    Article  PubMed  Google Scholar 

  42. Persson M, Osterberg T, Granérus AK, et al. Influence of Parkinson’s disease on oral health. Acta Odontol Scand 1992; 50: 37–42

    Article  PubMed  CAS  Google Scholar 

  43. Sockalingam S, Shammi C, Remington G. Clozapine-induced hypersalivation: a review of treatment strategies. Can J Psychiatry 2007; 52: 377–84

    PubMed  Google Scholar 

  44. Hori T, Makabe K, Nemoto K, et al. Hypersalivation induced by olanzapine with fluvoxamine. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30: 758–60

    Article  PubMed  CAS  Google Scholar 

  45. Donaldson SR. Sialorrhea as a side effect of lithium: a case report. Am J Psychiatry 1982; 139: 1350–1

    PubMed  CAS  Google Scholar 

  46. Jankovic J. Treatment of hyperkinetic movement disorders with tetrabenazine: a double-blind crossover study. Ann Neurol 1982 Jan; 11(1): 41–7

    Article  PubMed  CAS  Google Scholar 

  47. Müller T, Welnic J, Fuchs G, et al. The DONPAD study: treatment of dementia in patients with Parkinson’s disease with donepezil. J Neural Transm Suppl 2006; 71: 27–30

    Article  PubMed  Google Scholar 

  48. Freudenreich O, Herz L, Deckersbach T, et al. Added donepezil for stable schizophrenia: a double-blind, placebo-controlled trial. Psychopharmacology 2005; 181: 358–63

    Article  PubMed  CAS  Google Scholar 

  49. Jankovic J. Motor fluctuations and dyskinesias in Parkinson’s disease: clinical manifestations. Mov Disord 2005; 20Suppl. 11: S11–6

    Article  PubMed  Google Scholar 

  50. Santens P, de Noordhout AM, Belgian EODWO Study Group. Detection of motor and non-motor symptoms of end-of dose wearing-off in Parkinson’s disease using a dedicated questionnaire: a Belgian multicenter survey. Acta Neurol Belg 2006 Sep; 106(3): 137–41

    PubMed  Google Scholar 

  51. Merello MJ, Leiguarda RC. Adynamic bowel syndrome with dramatic response to apomorphine. Clin Neuropharmacol 1994; 17: 574–8

    Article  Google Scholar 

  52. Chauncey HH, Feller RP, Kapur KK. Longitudinal age-related changes in human parotid saliva composition. J Dent Res 1987; 66: 599–602

    Article  PubMed  CAS  Google Scholar 

  53. Tumilasci OR, Cersosimo MG, Belferte JE, et al. Quantitative study of salivary secretion in Parkinson’s disease. Mov Disord 2006; 21: 660–7

    Article  PubMed  Google Scholar 

  54. Aung W, Murata Y, Ishida R, et al. Study of quantitative oral radioactivity in salivary gland scintigraphy and determination of the clinical stage of Sjogren’s syndrome. J Nucl Med 2001; 42: 38–43

    PubMed  CAS  Google Scholar 

  55. Pai S, Ghezzi E, Ship J, et al. Development of a visual analogue scale questionnaire for subjective assessment of salivary dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91: 311–6

    Article  PubMed  CAS  Google Scholar 

  56. White KD. Salivation: a review and experimental investigation of major techniques. Psychophysiology 1977; 14: 203–12

    Article  PubMed  CAS  Google Scholar 

  57. Jones JM, Watkins CA, Hand JS, et al. Comparison of three salivary flow rate assessment methods in an elderly population. Community Dent Oral Epidemiol 2000; 28: 177–84

    Article  PubMed  CAS  Google Scholar 

  58. Jongerius PH, van Limbeek J, Rotteveel JJ. Assessment of salivary flow rate: biologic variation and measure error. Laryngoscope 2004; 114: 1801–4

    Article  PubMed  Google Scholar 

  59. Ramaker C, Marinus J, Stiggelbout AM, et al. Systematic evaluation of rating scales for impairment and disability in Parkinson’s disease. Mov Disord 2002; 17(5): 867–76

    Article  PubMed  Google Scholar 

  60. Marks L, Turner K, O’Sullivan J, et al. Drooling in Parkinson’s disease: a novel speech and language therapy intervention. Int J Lang Commun Disord 2001; 36 Suppl.: 282–7

    Article  PubMed  Google Scholar 

  61. Thomas-Stonell N, Greenberg J. Three treatment approaches and clinical factors in the reduction of drooling. Dysphagia 1988; 3(2): 73–8

    Article  PubMed  CAS  Google Scholar 

  62. Perez Lloret S, Piran Arce G, Rossi M, et al. Validation of a new scale for the evaluation of sialorrhea in patients with Parkinson’s disease. Mov Disord 2007; 22: 107–11

    Article  PubMed  Google Scholar 

  63. Jongerius PH, van Tiel P, van Limbeek J, et al. A systematic review for evidence of efficacy of anticholinergic drugs to treat drooling. Arch Dis Child 2003 Oct; 88(10): 911–4

    Article  PubMed  CAS  Google Scholar 

  64. Camp-Bruno JA, Winsberg BG, Green-Parsons AR, et al. Efficacy of benztropine therapy for drooling. Dev Med Child Neurol 1989; 31: 309–19

    Article  PubMed  CAS  Google Scholar 

  65. Gillis MC, ed. Robinul product monograph. In: Compendium of Pharmaceuticals and specialties. Toronto (ON): Canadian Pharmacists Association, 1999: 1578–9

  66. Blasco PA, Stansbury JCK. Glycopyrrolate treatment of chronic drooling. Arch Pediatr Adolesc Med 1996; 150: 932–5

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  Google Scholar 

  68. Fox S, Thomsen T, Asante A, et al. Ipratropium bromide spray as a treatment of sialorrhea in Parkinson’s disease [abstract]. Mov Disorders 2006; 21Suppl. 15: S573

    Google Scholar 

  69. Hyson HC, Johnson AM, Jog MS. Sublingual atropine for sialorrhea secondary to parkinsonism: a pilot study. Mov Disord 2002; 17(6): 1318–20

    Article  PubMed  Google Scholar 

  70. Heine RG, Catto-Smith AG, Reddihough DS. Effect of antireflux medication on salivary drooling in children with cerebral palsy. Dev Med Child Neurol 1996; 38: 1030–6

    Article  PubMed  CAS  Google Scholar 

  71. Newall AR, Orser R, Hunt M. The control of oral secretions in bulbar ALS/MND. J Neurol Sci 1996; 139 Suppl.: 43–4

    Article  PubMed  Google Scholar 

  72. Grabowski J. Clonidine treatment of clozapine-induced hypersalivation. J Clin Psychopharmacol 1992; 12(1): 69–70

    Article  PubMed  CAS  Google Scholar 

  73. Webber MA, Szwast SJ, Steadman TM, et al. Guanfacine treatment of Clozapine induced sialorrhea. J Clin Psychopharmacol 2004; 24(6): 675–6

    Article  PubMed  Google Scholar 

  74. Kushnir M, Eilam A, Heldman E. Modafinil reduces drooling in Parkinson’s disease. Mov Disord 2006; 21Suppl. 15: S598–9

    Google Scholar 

  75. Bushara KO. Sialorrhea in amyotrophic lateral sclerosis: a hypothesis of a new treatment — botulinum toxin A injections of the parotid glands. Med Hypotheses 1997; 48: 337–9

    Article  PubMed  CAS  Google Scholar 

  76. Dogu O, Apaydin D, Sevim S, et al. Ultrasound-guided versus ‘blind’ intraparotid injections of botulinum toxin-A for the treatment of sialorrhoea in patients with Parkinson’s disease. Clin Neurol Neurosurg 2004; 106: 93–6

    Article  PubMed  Google Scholar 

  77. Lagalla G, Millevolte M, Capecci M, et al. Botulinum toxin type A for drooling in Parkinson’s disease: a double-blind, randomized, placebo-controlled study. Mov Disord 2006; 21: 704–7

    Article  PubMed  Google Scholar 

  78. Lipp A, Trottenberg T, Schink T, et al. A randomized trial of botulinum toxin A for treatment of drooling. Neurology 2003; 61: 1279–81

    Article  PubMed  CAS  Google Scholar 

  79. Mancini F, Zangaglia R, Cristina S, et al. Double-blind, placebo-controlled study to evaluate the efficacy and safety of botulinum toxin type A in the treatment of drooling in parkinsonism. Mov Disord 2003; 18: 685–8

    Article  PubMed  Google Scholar 

  80. Ondo WG, Hunter C, Moore W. A double-blind placebo-controlled trial of botulinum toxin B for sialorrhea in Parkinson’s disease. Neurology 2004; 62: 37–40

    Article  PubMed  CAS  Google Scholar 

  81. Molloy L. Treatment of sialorrhea in patients with Parkinson’s disease: best current evidence. Curr Opin Neurol 2007; 20: 493–8

    Article  PubMed  CAS  Google Scholar 

  82. Andersen PM, Gronberg H, Franzen L, et al. External radiation of the parotid glands significantly reduces drooling in patients with motor neurone disease with bulbar paresis. J Neurol Sci 2001; 191: 111–4

    Article  PubMed  CAS  Google Scholar 

  83. Stalpers LJ, Moser EC. Results of radiotherapy for drooling in amyotrophic lateral sclerosis. Neurology 2002; 58: 1308

    Article  PubMed  Google Scholar 

  84. Borg M, Hirst F. The role of radiation therapy in the management of sialorrhea. Int J Radiat Oncol Biol Phys 1998; 41: 1113–9

    Article  PubMed  CAS  Google Scholar 

  85. Schneider AB, Lubin J, Ron E, et al. Salivary gland tumors after childhood radiation treatment for benign conditions of the head and neck: dose-response relationships. Radiat Res 1998; 149: 625–30

    Article  PubMed  CAS  Google Scholar 

  86. Shigematsu H, Magoshi S, Suzuki S, et al. An apparent radiation-induced carcinoma of the parotid gland following treatment for adenoid cystic carcinoma of the sublingual gland: a case report. J Oral Maxillofac Surg 2004; 62: 1169–74

    Article  PubMed  Google Scholar 

  87. Ward MJ, Levine PA. Salivary gland tumors. In: Close LG, Larson DL, Shah JP, editors. Essentials of head and neck oncology. New York: Thieme, 1998

    Google Scholar 

  88. Postma AG, Heesters M, van Laar T. Radiotherapy to the salivary glands as treatment of sialorrhea in patients with parkinsonism. Mov Disorders 2007: 22; 2430–5

    Article  Google Scholar 

  89. Limbrock GJ, Fischer-Brandies H, Avalle C. Castillo-Morales’ orofacial therapy: treatment of 67 children with Down syndrome. Dev Med Child Neurol 1991; 33(4): 296–303

    Article  PubMed  CAS  Google Scholar 

  90. Crysdale WS, McCann C, Roske L, et al. Saliva control issues in the neurologically challenged: a 30 year experience in team management. Int J Pediatr Otorhinolaryngol 2006; 70(3): 519–27

    Article  PubMed  Google Scholar 

  91. Marks L, Turner K, O’Sullivan J, et al. Drooling in Parkinson’s disease: a novel speech and language therapy intervention. Int J Lang Commun Disord 2001; 36 Suppl.: 282–7

    Article  PubMed  Google Scholar 

  92. Meningaud JP, Pitak-Arnnop P, Chikhani L, et al. Drooling of saliva: a review of the etiology and management options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101: 48–57

    Article  PubMed  Google Scholar 

  93. Grewal DS, Hiranandani NL, Rangwalla ZA, et al. Transtympanic neurectomies for control of drooling. Auris Nasus Larynx 1984; 11(2): 109–14

    PubMed  CAS  Google Scholar 

  94. Mullins WM, Gross CW, Moore JM. Long-term follow-up of tympanic neurectomy for sialorrhea. Laryngoscope 1979; 89(8): 1219–23

    PubMed  CAS  Google Scholar 

  95. Brundage SR, Moore WD. Submandibular gland resecton and bilateral parotid duct ligation as a management for chronic drooling in cerebral palsy. Plast Reconstr Surg 1989 Mar; 83(3): 443–6

    Article  PubMed  CAS  Google Scholar 

  96. Becmeur F, Horta-Geraud P, Brunot B, et al. Diversion of salivary flow to treat drooling in patients with cerebral palsy. J Pediatr Surg 1996 Dec; 31(12): 1629–33

    Article  PubMed  CAS  Google Scholar 

  97. Hamani C, Neimat J, Lozano AM. Deep brain stimulation for the treatment of Parkinson’s disease. J Neural Transm Suppl. 2006; 70: 393–9

    Article  PubMed  Google Scholar 

  98. Merello M, Starkstein S, Nouzeilles MI, et al. Bilateral pallidotomy for treatment of Parkinson’s disease induced corticobulbar syndrome and psychic akinesia avoidable by globus pallidus lesion combined with contralateral stimulation. J Neurol Neurosurg Psychiatry 2001; 71: 611–4

    Article  PubMed  CAS  Google Scholar 

  99. Ghika J, Ghika-Schmid F, Fankhauser H, et al. Bilateral contemporaneous posteroventral pallidotomy for the treatment of Parkinson’s disease: neuropsychological and neurological side effects: report of four cases and review of the literature. J Neurosurg 1999; 91: 313–21

    Article  PubMed  CAS  Google Scholar 

  100. Merello M. Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson’s disease. In: Tarsy D, Okun M, Vitek J, et al., eds. Deep brain stimulation in neurological and psychiatric disorders. Totowa (NJ): Humana Press; 2008: 253–76

    Chapter  Google Scholar 

  101. Serrano-Dueñas M. Sialorrhea in patients with Parkinson: a six year prospective study. Rev Neurol 2003; 37: 623–6

    PubMed  Google Scholar 

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  1. Neuroscience Department, Raul Carrea Institute for Neurological Research (FLENI), Montañeses 2325, Buenos Aires, Argentina

    Marcelo Merello

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Merello, M. Sialorrhoea and Drooling in Patients with Parkinson’s Disease. Drugs Aging 25, 1007–1019 (2008). https://doi.org/10.2165/0002512-200825120-00003

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