Advertisement

Saliva Management

  • Charley CoffeyEmail author
Chapter
  • 52 Downloads

Abstract

Neuromuscular and neurodegenerative disease can result in significant risk of aspiration of saliva and respiratory secretions. Inability to adequately clear saliva can also result in problematic drooling, throat clearing, and cough, with significant quality of life implications. A variety of techniques may be employed to address sialorrhea and drooling, with treatment selection dictated by severity of symptoms, tolerability of side effects, individual preference, and availability of techniques. Behavioral approaches focus on improving salivary clearance and can be employed in conjunction with broader efforts to improve swallowing function. Pharmacologic treatment focuses on reducing salivary production and includes a range of oral, topical, transdermal, or injectable options. Anticholinergic medications can prove effective, but are characterized by parasympathetic side effects that frequently limit tolerance. Central anticholinergic effects may also preclude use in patients with dementia or cognitive impairment. Botulinum neurotoxin (BoNT) injection directly into major salivary glands offers an effective longer term means of reducing saliva production with minimal adverse effects. BoNT injection can be performed in a clinic setting with ultrasound guidance to aid precision injection and can be repeated as needed for durable benefit. Surgical options such as ductal ligation or re-routing may offer permanent solutions for patients unable or unwilling to undergo serial BoNT injections. External beam radiation therapy targeting major salivary glands can reduce saliva production in selected patients who fail other treatments, though acute toxicities and long-term risks preclude widespread use. Successful approaches may vary significantly across patients and may require changing strategies based upon disease progression.

Keywords

Saliva Drooling Secretions Sialorrhea Botulinum Neuromuscular Neurodegenerative Swallowing Parasympathetic Anticholinergic 

References

  1. 1.
    Holsinger FC, Bui DT. Anatomy, function, and evaluation of the salivary glands. In: Myers EN, Ferris RL, editors. Salivary gland disorders. Berlin: Springer Science & Business Media; 2007.Google Scholar
  2. 2.
    Dawes C, Pedersen AML, Villa A, Ekström J, Proctor GB, Vissink A, et al. The functions of human saliva: a review sponsored by the World Workshop on Oral Medicine VI. Arch Oral Biol. 2015;60(6):863–74.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Navazesh M, Kumar S. Measuring salivary flow: challenges and opportunities. J Am Dent Assoc. 2008;139:35s–40s.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Dawes C. Physiological factors affecting salivary flow rate, oral sugar clearance, and the sensation of dry mouth in man. J Dent Res. 1987;66(1 Suppl):648–53.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38(3):236–40.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Dand P, Sakel M. The management of drooling in motor neurone disease. Int J Palliat Nurs. 2010;16(11):560–4.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Srivanitchapoom P, Pandey S, Hallett M. Drooling in Parkinson’s disease: a review. Parkinsonism Relat Disord. 2014;20(11):1109–18.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Nóbrega AC, Rodrigues B, Torres AC, Scarpel RD, Neves CA, Melo A. Is drooling secondary to a swallowing disorder in patients with Parkinson’s disease? Parkinsonism Relat Disord. 2008;14(3):243–5.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kalf JG, Smit AM, Bloem BR, Zwarts MJ, Munneke M. Impact of drooling in Parkinson’s disease. J Neurol. 2007;254(9):1227–32.CrossRefGoogle Scholar
  10. 10.
    Marks L, Turner K, O'Sullivan J, Deighton B, Lees A. Drooling in Parkinson’s disease: a novel speech and language therapy intervention. Int J Lang Commun Disord. 2001.;36 Suppl;36:282–7.CrossRefGoogle Scholar
  11. 11.
    Bagheri H, Damase-Michel C, Lapeyre-Mestre M, Cismondo S, O'Connell D, Senard JM, et al. A study of salivary secretion in Parkinson’s disease. Clin Neuropharmacol. 1999;22(4):213–5.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Proulx M, De Courval FP, Wiseman MA, Panisset M. Salivary production in Parkinson’s disease. Mov Disord. 2005;20(2):204–7.CrossRefGoogle Scholar
  13. 13.
    Nicaretta DH, de Rosso ALZ, Maliska C, Costa MMB. Scintigraphic analysis of the parotid glands in patients with sialorrhea and Parkinson’s disease. Parkinsonism Relat Disord. 2008;14(4):338–41.CrossRefGoogle Scholar
  14. 14.
    Baltadzhieva R, Gurevich T, Korczyn AD. Autonomic impairment in amyotrophic lateral sclerosis. Curr Opin Neurol. 2005;18(5):487–93.CrossRefGoogle Scholar
  15. 15.
    Giess R, Werner E, Beck M, Reiners C, Toyka KV, Naumann M. Impaired salivary gland function reveals autonomic dysfunction in amyotrophic lateral sclerosis. J Neurol. 2002;249(9):1246–9.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Charchaflie RJ, Fernandez LB, Perec CJ, Gonzalez E, Marzi A. Functional studies of the parotid and pancreas glands in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry. 1974;37(7):863–7.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Ozdilek B, Gunal DI. Motor and non-motor symptoms in Turkish patients with Parkinson’s disease affecting family caregiver burden and quality of life. J Neuropsychiatry Clin Neurosci. 2012;24(4):478–83.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Young CA, Ellis C, Johnson J, Sathasivam S, Pih N. Treatment for sialorrhea (excessive saliva) in people with motor neuron disease/amyotrophic lateral sclerosis. Cochrane Database Syst Rev. 2011;5:1–16.Google Scholar
  19. 19.
    Sufit RL, Miller RG, Mitsumoto H, Parry G, Ringel SP, Lessard D, The ALS CARE Study Group. Prevalence and treatment outcomes of sialorrhea in amyotrophic lateral sclerosis patients as assessed by the ALS Patient Care Database. Ann Neurol. 1999;46(3):506.Google Scholar
  20. 20.
    Bloem BR, Kalf JG, van de Kerkhof PCM, Zwarts MJ. Debilitating consequences of drooling. J Neurol. 2009;256(8):1382–3.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Nóbrega AC, Rodrigues B, Melo A. Silent aspiration in Parkinson’s disease patients with diurnal sialorrhea. Clin Neurol Neurosurg. 2008;110(2):117–9.CrossRefGoogle Scholar
  22. 22.
    Rodrigues B, Nóbrega AC, Sampaio M, Argolo N, Melo A. Silent saliva aspiration in Parkinson’s disease. Mov Disord. 2011;26(1):138–41.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Yeh CK, Johnson DA, Dodds MWJ. Impact of aging on human salivary gland function: a community-based study. Aging Clin Exp Res. 1998;10(5):421–8.CrossRefGoogle Scholar
  24. 24.
    Kim S-K, Allen ED. Structural and functional changes in salivary glands during aging. Microsc Res Tech. 1994;28(3):243–53.CrossRefGoogle Scholar
  25. 25.
    Nagler RM. Salivary glands and the aging process: mechanistic aspects, health-status and medicinal-efficacy monitoring. Biogerontology. 2004;5(4):223–33.CrossRefGoogle Scholar
  26. 26.
    Langmore SE, Miller RM. Behavioral treatment for adults with oropharyngeal dysphagia. Arch Phys Med Rehabil. 1994;75(10):1154–60.CrossRefGoogle Scholar
  27. 27.
    Ray SA, Bundy AC, Nelson DL. Decreasing drooling through techniques to facilitate mouth closure. Am J Occup Ther. 1983;37(11):749–53.CrossRefGoogle Scholar
  28. 28.
    Iammatteo PA, Trombly C, Luecke L. The effect of mouth closure on drooling and speech. Am J Occup Ther. 1990;44(8):686–91.CrossRefGoogle Scholar
  29. 29.
    Koheil R, Sochaniwskyj AE, Bablich K, Kenny DJ, Milner M. Biofeedback techniques and behavior modification in the conservative remediation of drooling by children with cerebral palsy. Dev Med Child Neurol. 1987;29(1):19–26.CrossRefGoogle Scholar
  30. 30.
    Baum BJ. Neurotransmitter control of secretion. J Dent Res. 1987;66(Spec No):628–632.Google Scholar
  31. 31.
    Baum BJ, Wellner RB. Receptors in salivary glands. In: Garrett JR, Ekström J, Anderson LC, editors. Neural mechanisms of salivary gland secretion, Frontiers of oral biology, vol. 11. Karger Publishers: Basel; 1999. p. 44–58.CrossRefGoogle Scholar
  32. 32.
    Newall AR, Orser R, Hunt M. The control of oral secretions in bulbar ALS/MND. J Neurol Sci. 1996;139(Suppl):43–4.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Tumilasci OR, Cersósimo MG, Belforte JE, Micheli FE, Benarroch EE, Pazo JH. Quantitative study of salivary secretion in Parkinson’s disease. Mov Disord. 2006;21(5):660–7.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Meningaud J-P, Pitak-Arnnop P, Chikhani L, Bertrand JC. Drooling of saliva: a review of the etiology and management options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(1):48–57.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Mier RJ, Bachrach SJ, Lakin RC, Barker T, Childs J, Moran M. Treatment of sialorrhea with glycopyrrolate: a double-blind, dose-ranging study. Arch Pediatr Adolesc Med. 2000;154(12):1214–8.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Arbouw MEL, Movig KLL, Koopmann M, Poels PJE, Guchelaar HJ, Egberts TCG, et al. Glycopyrrolate for sialorrhea in Parkinson disease: a randomized, double-blind, crossover trial. Neurology. 2010;74(15):1203–7.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Copp PJ, Lament R, Tennent TG. Amitriptyline in clozapine-induced sialorrhoea. Br J Psychiatry. 1991;159:166.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Praharaj SK, Arora M. Amitriptyline for clozapine-induced nocturnal enuresis and sialorrhoea. Br J Clin Pharmacol. 2007;63(1):128–9.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Sinha S, Simlai J, Praharaj SK. Very low dose amitriptyline for clozapine-associated sialorrhea. Curr Drug Saf. 2016;11(3):262–3.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Seppi K, Weintraub D, Coelho M, Perez Lloret S, Fox SH, Katzenschlager R, et al. The Movement Disorder Society evidence-based medicine review update: treatments for the non-motor symptoms of Parkinson’s disease. Mov Disord. 2011;26(Suppl 3):S42–80.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Brodtkorb E, Wyzocka-Bakowska MM, Lillevold PE, Sandvik L, Saunte C, Hestnes A. Transdermal scopolamine in drooling. J Intellect Disabil Res. 1988;32(3):233–7.CrossRefGoogle Scholar
  42. 42.
    Talmi YP, Finkelstein Y, Zohar Y. Reduction of salivary flow with transdermal scopolamine: a four-year experience. Otolaryngol Head Neck Surg. 1990;103(4):615–8.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    McGeachan AJ, Hobson EV, Al-Chalabi A, Stephenson J, Chandran S, Crawley F, et al. A multicentre evaluation of oropharyngeal secretion management practices in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener. 2017;18(1–2):1–9.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Comley C, Galletly C, Ash D. Use of atropine eye drops for clozapine induced hypersalivation. Aust N Z J Psychiatry. 2000;34(6):1033–4.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Hyson HC, Johnson AM, Jog MS. Sublingual Atropine for sialorrhea secondary to parkinsonism: a pilot study. Mov Disord. 2002;17(6):1318–20.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    De Simone GG, Eisenchlas JH, Junin M, Pereyra F, Brizuela R. Atropine drops for drooling: a randomized controlled trial. Palliat Med. 2016;20(7):665–71.CrossRefGoogle Scholar
  47. 47.
    Thomsen TR, Galpern WR, Asante A, Arenovich T, Fox SH. Ipratropium bromide spray as treatment for sialorrhea in Parkinson’s disease. Mov Disord. 2007;22(15):2268–73.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Lloret SP, Nano G, Carrosella A, Gamzu E, Merello M. A double-blind, placebo-controlled, randomized, crossover pilot study of the safety and efficacy of multiple doses of intra-oral tropicamide films for the short-term relief of sialorrhea symptoms in Parkinson’s disease patients. J Neurol Sci. 2011;310(1–2):248–50.CrossRefGoogle Scholar
  49. 49.
    McGeachan AJ, McDermott CJ. Management of oral secretions in neurological disease. Pract Neurol. 2017;17(2):96–103.CrossRefGoogle Scholar
  50. 50.
    Banfi P, Ticozzi N, Lax A, Guidugli GA, Nicolini A, Silani V. A review of options for treating sialorrhea in amyotrophic lateral sclerosis. Respir Care. 2015;60(3):446–54.CrossRefGoogle Scholar
  51. 51.
    Hawkey NM, Zaorsky NG, Galloway TJ. The role of radiation therapy in the management of sialorrhea: a systematic review. Laryngoscope. 2016;126(1):80–5.CrossRefGoogle Scholar
  52. 52.
    Ron E, Modan B, Boice JD, Alfandary E, Stovall M, Chetrit A, et al. Tumors of the brain and nervous system after radiotherapy in childhood. N Engl J Med. 1988;319(16):1033–9.CrossRefGoogle Scholar
  53. 53.
    Berrington de Gonzalez A, Kutsenko A, Rajaraman P. Sarcoma risk after radiation exposure. Clin Sarcoma Res. 2012;2(1):18.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Reed J, Mans CK, Brietzke SE. Surgical management of drooling: a meta-analysis. Arch Otolaryngol Head Neck Surg. 2009;135(9):924–31.CrossRefGoogle Scholar
  55. 55.
    Parisier SC, Blitzer A, Binder WJ, Friedman WF, Marovitz WF. Tympanic neurectomy and chorda tympanectomy for the control of drooling. Arch Otolaryngol. 1978;104(5):273–7.CrossRefGoogle Scholar
  56. 56.
    Withrow K, Sialorrhea CT. In: Gillespie MB, Walvekar RR, Schaitkin B, Eisele DW, editors. Gland-preserving salivary surgery. Cham: Springer International; 2018. p. 185–92.CrossRefGoogle Scholar
  57. 57.
    Spock T, Hoffman HT, Joshi AS. Transoral submandibular ganglion neurectomy: an anatomical feasibility study. Ann Otol Rhinol Laryngol. 2014;124(5):341–4.CrossRefGoogle Scholar
  58. 58.
    Ozturk K, Erdur O, Gul O, Olmez A. Feasibility of endoscopic submandibular ganglion neurectomy for drooling. Laryngoscope. 2017;127(7):1604–7.CrossRefGoogle Scholar
  59. 59.
    Khan WU, Islam A, Fu A, Blonski DC, Zaheer S, McCann CA, et al. Four-duct ligation for the treatment of sialorrhea in children. JAMA Otolaryngol Head Neck Surg. 2016;142(3):278–83.CrossRefGoogle Scholar
  60. 60.
    Shirley WP, Hill JS, Woolley AL, Wiatrak BJ. Success and complications of four-duct ligation for sialorrhea. Int J Ped Oto. 2003;67:1–6.CrossRefGoogle Scholar
  61. 61.
    Wilkie TF. The problem of drooling in cerebral palsy: a surgical approach. Can J Surg. 1967;10(1):60–7.PubMedGoogle Scholar
  62. 62.
    Cotton RT, Richardson MA. The effect of submandibular duct rerouting in the treatment of sialorrhea in children. Otolaryngol Head Neck Surg. 1981;89(4):535–41.CrossRefGoogle Scholar
  63. 63.
    Crysdale WS. Management options for the drooling patient. Ear Nose Throat J. 1989;68(11):820, 825–6–829–30PubMedGoogle Scholar
  64. 64.
    Crysdale WS, Raveh E, McCann C, Roske L, Kotler A. Management of drooling in individuals with neurodisability: a surgical experience. Dev Med Child Neurol. 2001;43(6):379–83.CrossRefGoogle Scholar
  65. 65.
    Sobocki PA, Arnrup K, Bensch J, Gertzén H, Wranne L. Submandibular duct retroposition reduces drooling, but may cause caries in lower front teeth. Dev Med Child Neurol. 1992;34(6):556–6.Google Scholar
  66. 66.
    Hallett KB, Lucas JO, Johnston T, Reddihough DS, Hall RK. Dental health of children with cerebral palsy following sialodochoplasty. Spec Care Dentist. 1995;15(6):234–8.CrossRefGoogle Scholar
  67. 67.
    Evatt ML, Chaudhuri KR, Chou KL, Cubo E, Hinson V, Kompoliti K, et al. Dysautonomia rating scales in Parkinson’s disease: sialorrhea, dysphagia, and constipation—critique and recommendations by movement disorders task force on rating scales for Parkinson’s disease. Mov Disord. 2009;24(5):635–46.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Thomas-Stonell N, Greenberg J. Three treatment approaches and clinical factors in the reduction of drooling. Dysphagia. 1988;3(2):73–8.CrossRefGoogle Scholar
  69. 69.
    Perez Lloret S, Pirán Arce G, Rossi M, Caivano Nemet ML, Salsamendi P, Merello M. Validation of a new scale for the evaluation of sialorrhea in patients with Parkinson’s disease. Mov Disord. 2007;22(1):107–11.CrossRefGoogle Scholar
  70. 70.
    Blasco PA. Management of drooling: 10 years after the Consortium on Drooling, 1990. Dev Med Child Neurol. 2002;44(11):778–81.CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Reddihough D, Erasmus CE, Johnson H, McKellar GMW, Jongerius PH. Botulinum toxin assessment, intervention and aftercare for paediatric and adult drooling: international consensus statement. Eur J Neurol. 2010;17(Suppl 2):109–21.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Petracca M, Guidubaldi A, Ricciardi L, Ialongo T, Del Grande A, Mulas D, et al. Botulinum Toxin A and B in sialorrhea: long-term data and literature overview. Toxicon. 2015;107(Pt A):129–40.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Guidubaldi A, Fasano A, Ialongo T, Piano C, Pompili M, Mascianà R, et al. Botulinum toxin A versus B in sialorrhea: a prospective, randomized, double-blind, crossover pilot study in patients with amyotrophic lateral sclerosis or Parkinson’s disease. Mov Disord. 2011;26(2):313–9.CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    Dressler D. Clinical presentation and management of antibody-induced failure of botulinum toxin therapy. Mov Disord. 2004;1(Suppl 8):S92–S100.CrossRefGoogle Scholar
  75. 75.
    Chen JJ, Dashtipour K. Abo-, inco-, ona-, and rima-botulinum toxins in clinical therapy: a primer. Pharmacotherapy. 2013;33(3):304–18.CrossRefPubMedPubMedCentralGoogle Scholar
  76. 76.
    Anagnostou E, Evangelos A, Rentzos M, Michael R, Alexakis T, Theodoros A, et al. Volume matters: the influence of different botulinum toxin-a dilutions for sialorrhea in amyotrophic lateral sclerosis. Muscle Nerve. 2013;47(2):276–8.CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Vashishta R, Nguyen SA, White DR, Gillespie MB. Botulinum toxin for the treatment of sialorrhea: a meta-analysis. Otolaryngol Head Neck Surg. 2013;148(2):191–6.CrossRefPubMedPubMedCentralGoogle Scholar
  78. 78.
    Scaglione F. Conversion ratio between Botox®, Dysport®, and Xeomin® in clinical practice. Toxins (Basel). 2016;8:65.CrossRefGoogle Scholar
  79. 79.
    Restivo DA, Panebianco M, Casabona A, Lanza S, Marchese-Ragona R, Patti F, et al. Botulinum toxin a for sialorrhoea associated with neurological disorders: evaluation of the relationship between effect of treatment and the number of glands treated. Toxins (Basel). 2018;10(2):55.CrossRefGoogle Scholar
  80. 80.
    Dogu O, Apaydin D, Sevim S, Talas DU, Aral M. 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(2):93–6.CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Capaccio P, Torretta S, Osio M, Minorati D, Ottaviani F, Sambataro G, et al. Botulinum toxin therapy: a tempting tool in the management of salivary secretory disorders. Am J Otolaryngol. 2008;29(5):333–8.CrossRefPubMedPubMedCentralGoogle Scholar
  82. 82.
    Lagalla G, Millevolte M, Capecci M, Provinciali L, Ceravolo MG. Botulinum toxin type A for drooling in Parkinson’s disease: a double-blind, randomized, placebo-controlled study. Mov Disord. 2006;21(5):704–7.CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Jackson CE, Gronseth G, Rosenfeld J, Barohn RJ, Dubinsky R, Simpson CB, et al. Randomized double-blind study of botulinum toxin type B for sialorrhea in ALS patients. Muscle Nerve. 2009;39(2):137–43.CrossRefPubMedPubMedCentralGoogle Scholar
  84. 84.
    Chinnapongse R, Gullo K, Nemeth P, Zhang Y, Griggs L. Safety and efficacy of botulinum toxin type B for treatment of sialorrhea in Parkinson’s disease: a prospective double blind trial. Mov Disord. 2012;27(2):219–26.CrossRefPubMedPubMedCentralGoogle Scholar
  85. 85.
    Jeung IS, Lee S, Kim HS, Yeo CK. Effect of botulinum toxin a injection into the salivary glands for sialorrhea in children with neurologic disorders. Ann Rehabil Med. 2012;36(3):340–6.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Otolaryngology–Head & Neck Surgery, Department of SurgeryUniversity of California San DiegoLa JollaUSA

Personalised recommendations