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Vol. 101 No. 1

January 2006

ORAL MEDICINE

Editor: Martin S. Greenberg

Drooling of saliva: A review of the etiology and management optionsJean-Paul Meningaud, MD, PhD, FEBOMS,a Poramate Pitak-Arnnop, DDS, OMS,b Luc Chikhani, MD,c and Jacques-Charles Bertrand, MD,d Paris, FranceUNIVERSITY OF PIERRE & MARIE CURIE (PARIS 6)

Drooling of saliva appears to be the consequence of a dysfunction in the coordination of the swallowing mechanism, resulting in excess pooling of saliva in the anterior portion of the oral cavity and the unintentional loss of saliva from the mouth. Drooling can produce signicant negative effects on physical health and quality of life, especially in patients with chronic neurological disabilities. Various approaches to manage this condition have been described in the literature, including oral motor therapy, behavior modication via biofeedback, orofacial regulation therapy, drug therapy, radiotherapy, and surgical treatments. Minimally invasive modalities, such as injection of botulinum toxin, photocoagulation, and acupuncture, have also been reported. This article provides a comprehensive and thorough overview of drooling, with an emphasis on understanding its etiologies and modalities of treatment. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:48-57)

Drooling of saliva is dened as the inability to control oral secretions. This condition is not due to excessive production of saliva, but is rather a problem in the coordinated control mechanism of orofacial and palatolingual musculatures. Even patients who produce less saliva can suffer from drooling (eg, patients with Parkinsons disease).1,2 This impaired neurological control results in poor swallowing function and leads to excessive pooling of saliva in the anterior portion of the oral cavity and the unintentional loss of saliva from the mouth. Hypersalivation does not necessarily lead to drooling. Drooling can be highly distressful for neurologically impaired patients and their parents or caregivers; the risk of social rejection, constant wetness of clothing,This work was supported by a grant-in-aid 2005/2006 n04 for scien tic research from the Fondation des Gueules Cassees. a Consultant Maxillofacial Surgeon, Department of Maxillofacial ` Surgery, Teaching Pitie-Salpetriere Hospital, Paris, France. b Surgical fellow, Department of Maxillofacial Surgery, Teaching ` Pitie-Salpetriere Hospital, Paris, France. c Consultant Maxillofacial Surgeon, Department of Maxillofacial ` Surgery, Teaching Pitie-Salpetriere Hospital, Paris, France. d Professor, head of the department, Head Professor, Department of ` Maxillofacial Surgery, Teaching Pitie-Salpetriere Hospital, Paris, France. Received for publication Apr 7, 2005; returned for revision Jul 20, 2005; accepted for publication Aug 17, 2005. 1079-2104/$ - see front matter 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.08.018

and physical discomfort adds further burden to the special attention required by these patients. Besides its cosmetic effects, drooling can impair masticatory function, interfere with speech, favor perioral infections, particularly by Candida albicans, and result in loss of uid, electrolytes, and proteins, deteriorating the quality of life of the patient. The inability to swallow adequately also increases the risk of aspiration pneumonia. The aim of this article is to provide a comprehensive and thorough overview of drooling with an emphasis on understanding the causal mechanisms and modalities of treatment. MATERIALS AND METHODS Articles, from 1966 onward, were identied with Medline using key words (drooling and sialorrhea) and the limits function. Only original clinical studies written in English and French were retained for review. Articles were selected keeping in mind the specic experience of each author. For the table summarizing the literature on salivary duct and gland procedures, data were gathered only from series including more than 10 patients and using an assessment tool. Many systems have been advocated for assessment of drooling. The following are just a few examples. To obtain an objective measurement, saliva produced spontaneously during a 5-minute period can be collected from the mouth. The drooling quotient (DQ)3,4 is a validated, semiquantitative, direct observational method. The

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presence or absence of drooling is assessed every 15 seconds during two 10-minute periods separated by a 60-minute break. The success of surgical treatment is generally assessed with the criteria described by Wilkie and Brody:5 outcome is considered excellent if salivary control is apparently normal, good if there is a slight loss of saliva, fair if drooling is improved but with signicant residual loss of saliva, and poor if no signicant control is observed. Successful surgical removal includes procedures with excellent or good outcomes. Physiology of swallowing Swallowing is a physiological process which can be initiated voluntarily but is thereafter under reex control. It begins with tactile stimulation of pharyngeal receptors that send impulses to the integrative areas for swallowingcalled swallowing centers in the medulla and pons.6 Motor output from this center, transmitted via the trigeminal, facial, glossopharyngeal, vagus, accessory, and hypoglossal nerves, controls the sequential peristaltic coordination of pharyngeal and upper esophageal muscles that contract during swallowing. Descending inputs from cortical and subcortical centers can initiate or regulate swallowing.7 Etiologies of drooling Causes of drooling are summarized in Table I. Drooling is a physiological phenomenon in infants, which usually resolves after 15-18 months of age as a result of the maturation process of the orofacial motor function and the coordination of swallowing; it has been dened as an abnormality in a child more than 4 years of age in the awake status.8 Drooling is a relatively common clinical sign; for instance, the Oxford Feeding Study estimated that 28% of children with neurological impairment suffer from continuous drooling.9 According to Tahmassebis10 survey, 58% of children with cerebral palsy have a drooling condition, which is severe in 33% of them. As noted in Hysons survey,11 46.5% of parkinsonian patients complained about drooling, 18.8% of whom felt that their drooling was socially disabling. Even in the early phases of Parkinsons disease, 15% of patients suffer from nocturnal drooling.12 Management of drooling A multidisciplinary team is indispensable for appropriate assessment and management of drooling. Any aggravating problem, for example, signicant dental disease, abnormal head position leading to abnormal salivary ow with gravity, severe malocclusion, airway obstruction, or certain drug effects, must be recognized and treated or relieved.

Table I. The etiology of droolingCauses of drooling Neurological decits Cerebral palsy Motor neuron disease, notably amyotrophic lateral sclerosis (ALS) Facial paralysis Cerebrovascular accidents Seizures Parkinsons disease Congenital suprabulbar palsy Severe mental retardation; Down syndrome and patients with physical and/or learning disabilities Worster Drought syndrome Landau Kleffner syndrome Encephalitis Anglemans syndrome Hydrocephalus Hypoxic encephalopathy Freeman-Sheldon syndrome Moebius syndrome Idiopathic Major resection of oropharynx Adverse drug reaction: clozapine Early sign of Sjogrens syndrome Painful swallowing caused by infectious diseases: primary herpes, Coxsackie virus, etc. Oral/dental problems Malocclusion Resorbed dental ridge Tongue thrust Constant open mouth and poor lip control (lip incompetency) Anesthesia or hypoesthesia of lips Congenital or acquired deformities of tongue

Nasal obstruction Hypoactive gag reex Gastro-esophageal reex Head posture and sitting position Concentration on a task/ degree of concentration Emotional state

Depending on the modality used, treatment of drooling can potentially complicate oral health. Such effects, notably the impact of decreased salivation, must always be taken into account. Saliva contributes signicantly to oral health. It functions as a buffer and a source of ions used for remineralization of teeth. Complications such as gingivitis, burning sensation of the mucous membrane, rampant caries, rapid tooth destruction, cheilitis, commissure ssuring, tongue and palate crusting, and occasionally paresthesia of the tongue or mucous membrane should be addressed. Regular dental examination for caries is recommended for all patients, and uoride supplementation might be helpful.

Nonsurgical methods for treating drooling problems Oral motor therapy. Oral motor programs aim to develop oral skills such as sucking, lip closure, and tongue and jaw movement. The speech therapist plays a crucial role in evaluating the existing oral motor

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Table II. Success and major complications of duct ligation/relocation and/or gland removal procedures for droolingReference (yr) Ekedahl (1974) Wilkie and Brody (1977)541

Duct relocation SM 3 2 P32

Duct ligation SL 3 2

Gland removal SM 3 2

Success (%) 9/11 (81%) 106/123 (86%)

Major complications (cases, %) Hematoma (1/11), total: 9% Duct stenosis or cyst (25/123), oral/ dental problems (9/123), transient parotid swelling (5/123), wound dehiscence (3/123), septic parotitis (1/123), total: 35% Cyst (2/6), transient swelling (1/6), total: 50% in the relocation group, 0% in the ligation group TMJ ankylosis (1/14), but relationship not sure Ranula (2/18), total: 11% Ranula (2/25), oor of mouth infection (1/25), swelling requiring operation (1/25), total: 16% Hematoma (1/24), wound infection (1/24), total: 8% Ranula (15/194), lateral cervical cyst (4