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ORAL MEDICINE Editor: Martin S. Greenberg

Drooling of saliva: A review of the etiology and management options

Jean-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 significant 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 modification 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)

Vol. 101 No. 1 January 20

Drooling of saliva is defined as the inability to controloral secretions. This condition is not due to excessiveproduction of saliva, but is rather a problem in the co-ordinated control mechanism of orofacial and palatolin-gualmusculatures. Evenpatientswhoproduce less salivacan suffer from drooling (eg, patients with Parkinson’sdisease).1,2 This impaired neurological control resultsin poor swallowing function and leads to excessive pool-ing of saliva in the anterior portion of the oral cavityand the unintentional loss of saliva from the mouth.Hypersalivation does not necessarily lead to drooling.

Drooling can be highly distressful for neurologicallyimpaired patients and their parents or caregivers; therisk of social rejection, constant wetness of clothing,

This work was supported by a grant-in-aid 2005/2006 n04 for scien-

tific research from the Fondation des Gueules Cassees.aConsultant Maxillofacial Surgeon, Department of Maxillofacial

Surgery, Teaching Pitie-Salpetriere Hospital, Paris, France.bSurgical fellow, Department of Maxillofacial Surgery, Teaching

Pitie-Salpetriere Hospital, Paris, France.cConsultant Maxillofacial Surgeon, Department of Maxillofacial

Surgery, Teaching Pitie-Salpetriere Hospital, Paris, France.dProfessor, 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

48

and physical discomfort adds further burden to the spe-cial attention required by these patients. Besides its cos-metic effects, drooling can impair masticatory function,interfere with speech, favor perioral infections, particu-larly by Candida albicans, and result in loss of fluid,electrolytes, and proteins, deteriorating the quality oflife of the patient. The inability to swallow adequatelyalso increases the risk of aspiration pneumonia.

The aim of this article is to provide a comprehensiveand thorough overview of drooling with an emphasis onunderstanding the causal mechanisms and modalitiesof treatment.

MATERIALS AND METHODSArticles, from 1966 onward, were identified with

Medline using key words (drooling and sialorrhea)and the ‘‘limits’’ function. Only original clinical studieswritten in English and French were retained for review.Articles were selected keeping in mind the specific ex-perience of each author. For the table summarizing theliterature on salivary duct and gland procedures, datawere gathered only from series including more than 10patients and using an assessment tool.

Many systems have been advocated for assessment ofdrooling. The following are just a few examples. To ob-tain an objective measurement, saliva produced sponta-neously during a 5-minute period can be collected fromthe mouth. The drooling quotient (DQ)3,4 is a validated,semiquantitative, direct observational method. The

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Volume 101, Number 1 Meningaud et al. 49

presence or absence of drooling is assessed every 15seconds during two 10-minute periods separated by a60-minute break. The success of surgical treatment isgenerally assessed with the criteria described by Wilkieand Brody:5 outcome is considered ‘‘excellent’’ if sali-vary control is apparently normal, ‘‘good’’ if there is aslight loss of saliva, ‘‘fair’’ if drooling is improved butwith significant residual loss of saliva, and ‘‘poor’’ ifno significant control is observed. Successful surgicalremoval includes procedures with ‘‘excellent’’ or ‘‘good’’outcomes.

Physiology of swallowingSwallowing is a physiological process which can be

initiated voluntarily but is thereafter under reflex con-trol. It begins with tactile stimulation of pharyngeal re-ceptors that send impulses to the integrative areas forswallowing—called ‘‘swallowing centers’’ in the me-dulla and pons.6Motor output from this center, transmit-ted via the trigeminal, facial, glossopharyngeal, vagus,accessory, and hypoglossal nerves, controls the sequen-tial peristaltic coordination of pharyngeal and upperesophageal muscles that contract during swallowing.Descending inputs from cortical and subcortical centerscan initiate or regulate swallowing.7

Etiologies of droolingCauses of drooling are summarized in Table I.

Drooling is a physiological phenomenon in infants,which usually resolves after 15-18 months of age as aresult of the maturation process of the orofacial motorfunction and the coordination of swallowing; it hasbeen defined as an abnormality in a child more than4 years of age in the awake status.8 Drooling is a rela-tively common clinical sign; for instance, the OxfordFeeding Study estimated that 28% of children with neu-rological impairment suffer from continuous drooling.9

According to Tahmassebi’s10 survey, 58% of childrenwith cerebral palsy have a drooling condition, whichis severe in 33% of them. As noted in Hyson’s survey,11

46.5% of parkinsonian patients complained about drool-ing, 18.8% of whom felt that their drooling was sociallydisabling. Even in the early phases of Parkinson’s dis-ease, 15% of patients suffer from nocturnal drooling.12

Management of droolingA multidisciplinary team is indispensable for ap-

propriate assessment and management of drooling. Anyaggravating problem, for example, significant dentaldisease, abnormal head position leading to abnormalsalivary flow with gravity, severe malocclusion, airwayobstruction, or certain drug effects, must be recognizedand treated or relieved.

Depending on the modality used, treatment of drool-ing can potentially complicate oral health. Such effects,notably the impact of decreased salivation, must alwaysbe taken into account. Saliva contributes significantly tooral health. It functions as a buffer and a source of ionsused for remineralization of teeth. Complications suchas gingivitis, burning sensation of the mucous mem-brane, rampant caries, rapid tooth destruction, cheilitis,commissure fissuring, tongue and palate crusting, andoccasionally paresthesia of the tongue or mucous mem-brane should be addressed. Regular dental examinationfor caries is recommended for all patients, and fluoridesupplementation might be helpful.

Nonsurgical methods for treatingdrooling problems

Oral motor therapy. Oral motor programs aim todevelop oral skills such as sucking, lip closure, andtongue and jaw movement. The speech therapist playsa crucial role in evaluating the existing oral motor

Table I. The etiology of drooling

Causes of drooling

Neurological deficits Oral/dental problems

Cerebral palsy Malocclusion

Motor neuron disease,

notably amyotrophic

lateral sclerosis (ALS)

Resorbed dental ridge

Facial paralysis

Tongue thrust

Cerebrovascular accidents

Constant open mouth and

poor lip control

(lip incompetency)

Seizures Anesthesia or hypoesthesia

of lipsParkinson’s disease

Congenital or acquired

deformities of tongue

Congenital suprabulbar palsy

Severe mental

retardation; Down syndrome

and patients with physical

and/or learning disabilities

Worster Drought syndrome

Landau Kleffner syndrome

Encephalitis

Angleman’s syndrome

Hydrocephalus

Hypoxic encephalopathy

Freeman-Sheldon syndrome

Moebius syndrome

Idiopathic

Major resection of oropharynx Nasal obstruction

Adverse drug reaction: clozapine Hypoactive gag reflex

Early sign of Sjogren’s syndrome Gastro-esophageal reflex

Painful swallowing caused by

infectious diseases: primary

Head posture and sitting

position

herpes, Coxsackie virus, etc.Concentration on a task/

degree of concentration

Emotional state

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50 Meningaud et al. January 2006

Table II. Success and major complications of duct ligation/relocation and/or gland removal procedures for drooling

Reference (yr)

Duct

relocation

Duct

ligation

Gland

removal Success (%) Major complications (cases, %)

Ekedahl (1974)41 SM 3 2 SL 3 2 — 9/11 (81%) Hematoma (1/11), total: 9%

Wilkie and Brody (1977)5 P 3 2 — SM 3 2 106/123 (86%) 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%

Glass et al. (1978)42 Compare P 3 2 ligation

versus P 3 2 relocation

SM 3 2 Better results in the

ligation group

Cyst (2/6), transient swelling (1/6),

total: 50% in the relocation group,

0% in the ligation group

Dundas and

Peterson (1979)43— P 3 2 SM 3 2 12/14 (85%) TMJ ankylosis (1/14), but

relationship not sure

Guerin (1979)44 SM 3 2 — — 18/18 (100%) Ranula (2/18), total: 11%

Cotton and

Richardson (1981)45SM 3 2 — — 24/25 (96%) Ranula (2/25), floor of mouth

infection (1/25), swelling requir-

ing operation (1/25), total: 16%

Shott et al. (1989)47 — P 3 2 SM 3 2 21/24 (87%) Hematoma (1/24), wound infection

(1/24), total: 8%

Crysdale and

White (1989)48SM 3 2 — — 95/107 (89%) Ranula (15/194), lateral cervical cyst

(4/194), total: 10%

Brundage and

Moore (1989)49— P 3 2 SM 3 2 50/58 (86%) Wound infection (2/58), hematomas

(2/58), parotid duct fistula (1/58),

parotitis (1/58), total: 10%

O Dwyer et al. (1989)50 SM 3 2 — — 13/16 1 aspiration pneumonia, total: 6%

Rosen et al. (1990)51 P 3 2 — SM 3 2 16/18 (89%) Ranula (1/18), xerostomia (1/18),

transient parotid swelling (1/18),

total: 16%

Burton et al. (1991)52 SM 3 2 — — 17/20 (85%) Retention cyst requiring operation

(2/20), resolved retention cyst

(2/20), 6 month swelling (1/20),

total: 25%

Varma et al. (1991)53 SM 3 2 P 3 2 — 13/14 (92%) Transient swelling (6/14), ranula

(1/14), total: 50%

Jacquinet et al. (1993)54 Compare Wilkie procedure

and SM ducts relocation

Results slightly better

in the Wilkie group

Parotid cyst (2/13), septic parotitis

(1/13), xerostomia (1/13), total

38% (Wilkie group)

mucoid cyst (2/5), total: 40%

(SM ducts relocation group)

Webb et al. (1995)55 SM 3 2 P 3 1 — Drooling quotient

improved in 100%

(N = 28)

Minor infection (6/39), ranula (5/39),

increase in dental carries (5/39),

dry mouth (9/39), aspiration

(2/39), total: 69%

O Dwyer and

Conlon56 (1997)

SM 3 2 94% of parents satisfied

(N = 53)

Ranula (4/54), aspiration pneumonia

(3/54), tooth extraction (3/54),

total: 18%

Ethunandan and

Macpherson (1998)57SM 3 2 — SL 3 2 16/19 (84%) Transient swelling (6/20), wound

infection (1/20), substantial bleed-

ing (1/20), total: 40%

Mankarious

et al. (1999)58SM 3 2 — — 47/59 (80%) mean time to

follow-up = 5.46 years

Ranula (7/79), SM gland infection

(1/79), transient swelling (1/79),

total: 10%

Wilson and

Henderson (1999)59SM 3 2 — — 12/16 (75%) Ranula (7/71), transient airway

obstruction (1/71), total: 11%

SM 3 2 P 3 1 — 47/49 (96%)

Panarese et al. (2001)60 SM 3 2 — — Short term: 82%

long-term: 76% (N = 35)

Dry, chapped lips (4/35), periodontal

disease (2/35), ranula (2/35),

persistent swelling (2/35), lower

lip droop (1/35), total: 31%

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Table II. Continued

Reference (yr)

Duct

relocation

Duct

ligation

Gland

removal Success (%) Major complications (cases, %)

Crysdale et al. (2001)61 SM 3 2 — — Improvement of scores

statistically similar

(106 and 115 patients)

Additional surgery for persistent

drooling (23/226), ranula (20/226),

lateral neck cyst (7/226), total:

22%

SM 3 2 — SL 3 2 Additional surgery for persistent

drooling (6/249), total: 2.5%

Stern et al. (2002)62 — P 3 2 SM 3 2 62/72 (87%) Hematoma (1/93), transient swelling

(1/93), parotitis (1/93), dry mouth

(7/72), increase in dental caries

(2/72), total: 15%

De et al. (2003)63 SM 3 2 — SL 3 2 49/56 (87%) Ranula (5/56), oral/dental problems

(4/56), secondary hemorrhage

(1/56), chest infection (1/56),

total: 19%

Uppal et al. (2003)64 SM 3 2 — SL 3 2 20/23 (87%) Sialadenitis (3/23), ranula (1/23),

persistent swelling (1/23),

total: 23%

Shirley et al. (2003)65 — P 3 2 and

SM 3 2

— 17/21 (81%) Ranula (1/21), sialadenitis (1/21),

total: 10%

SM, submandibular gland/duct; SL, sublingual gland/duct; P, parotid gland/duct.

skills of the patient. Harris and Dignam13 had positiveresults in cerebral-palsied children participating in atraining program using mirrors, games, relative com-petitiveness, and praise reinforcements by the physio-therapist, combined with a ‘‘chin cup’’ appliance toapply pressure on the chin to achieve an appropriateanterior oral seal.

Behavioralmodificationvia biofeedback.Biofeedbacktechniques condition the patient to swallow at the soundof an auditory stimulus. Koheil et al.14 reported the suc-cess of a training program using an auditory electromy-ography (EMG) feedback with electrodes placed on theorbicularis oris muscle. It was considered that patientsmust be old enough, have relatively good intellectualfunctions, be auditory-prompted, be reasonably well mo-tivated, present only a moderate drooling problem, andnot become oblivious to the auditory device or its signal.Subsequently, these techniques were not widely diffusedin clinical practice.

Orofacial regulation therapy. A functional appliance,employed according to the principles of Castillo-Morales, has been used successfully in the managementof drooling. It consists of an acrylic palatal plate withvestibular and lingual stimulators. The vestibular stimu-lator, formed by varying the depth of the ridge, stimu-lates the lip seal. The lingual stimulator is a medianbutton with a central hole that induces sucking, and sub-sequently, tongue retrusion.15,16 This appliance is veryhelpful for patients with hypotonic perioral musculatureand protruding tongue as commonly seen in Down’sand Moebius syndromes.17 Limbrock et al. found 68%

improvement in 53 patients with Down’s syndrome,18

and 72% improvement in cerebral-palsied patientswith severe drooling.19 When this method does notstop the drooling, it can at least reduce it. Combinationwith other methods remains possible. The appliance isnot well accepted by children less than 4 years old.

Drug therapy. Salivation is mainly mediated throughparasympathetic stimulation. Acetylcholine is the activeneurotransmitter, binding at muscarinic receptors in thesalivary glands. Thus, cholinergic muscarinic receptorantagonists such as atropine, scopolamine (hyoscine),or glycopyrronium bromide can be used to treat drool-ing. These drugs are contraindicated when there is ahistory of cardiac problems, closure glaucoma, prostatehypertrophy, paralytic ileus, or pyloric obstruction.Besides, the result is often incomplete with considerableindividual variation sometimes leading to high doseswith significant side effects such as excessively drymouth, constipation, urinary retention, blurred vision,irritability, confusion, and even toxic psychosis,20 whichpose greater risks to the health of the patient than sialor-rhea itself.

Sublingually administered atropine reduces drool-ing.21,22 Sublingual delivery has many advantages. Incontrast with botulinum toxin, the drug administeredin the form of ophthalmic drops is readily available.Atropine is inexpensive, does not require any special-ized skill for use, and unlike surgical removal, has a re-versible effect. However, it is contraindicated inpatients with cognitive impairment, dementia, and hal-lucination. Hyson et al.21 delivered 1 drop of atropine

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(1% wt/vol solution containing 0.5 mg) sublinguallytwice a daily.

Scopoderm transdermal therapeutic system (TTS)is a self-adhesive dermal patch delivering scopolamine,usually applied to prevent nausea associated with mo-tion sickness. Dryness of the mouth is its most commonside effect. It has been evaluated in patients who sufferfrom drooling induced by clozapine,23 brain injury,24

cerebral palsy,25,26 and major resection of the orophar-ynx.27 The lesser peak-concentration side effects are aspecific advantage. Potential side effects include a local-ized dermal reaction.28 Zeppetella29 successfully usedscopolamine via nebulization in 3 patients, 2 of whomhad not improved with the transdermal form. With neb-ulized delivery, scopolamine is absorbed faster and canbe used on an ‘‘as required’’ basis. In addition, nebulizedscopolaminemight be helpful for patients with problem-atic bronchial secretion.

Recently, Jongerius et al.30 performed a systematicreview to investigate the efficacy of anticholinergicdrugs in the treatment of drooling in children with mul-tiple handicaps. Although they reviewed the literaturefrom 1966, only 7 articles fit their chosen methodo-logical criteria. Based on their study, there was someevidence that at least some anticholinergic drugs (benz-tropine, glycopyrrolate, and benzhexol hydrochloride)are effective, but the authors were unable to concludethat one drug is preferable.

Radiotherapy. Borg and Hirst31 advised that radio-therapy should be avoided in children because of therisk of inducing malignancy, growth retardation, xero-stomia, mucositis, radiation caries, and osteoradione-crosis. Conversely, in elderly patients with a limitedlife expectancy, these long-term side effects wouldnot be expected to develop. After reviewing theirresults, the authors concluded that the desired re-sponse, with minimal discomfort of patients and with-out causing significant morbidity, can be expected withfive 4-Gy fractions to a total dose of 20 Gy using 9-18MeVelectrons prescribed to the 100% isodose, encom-passing both the parotid and submandibular glandswith ipsilateral fields. The development of thick secre-tion may be avoided by sparing the upper part of pa-rotid glands in the radiation field; reducing total doseand dose per fraction might prevent temporomandibu-lar joint fibrosis. Andersen et al.32 revealed theirsuccess in treating the severe drooling of 18 amyotro-phic lateral sclerosis patients with a life expectancy ofless than 2 years. Irradiation of the larger part of theparotid glands and the posterior part of the submandib-ular glands with 7.0-7.5 Gy in a single fractionreduced drooling without producing permanent xero-stomia, except in 1 patient. Findings reported byStalpers and Moser supported their results.33

Surgical methods for treating drooling problemsNeurectomy. Sectioning the parasympathetic neural

pathway reduces the flow of saliva. The tympanic plexusand the chorda tympani nerves can be sectioned,34,35

either unilaterally or bilaterally, and either alone or incombination with other procedures such as submandib-ular gland removal.36 Chorda tympani neurectomyreduces the salivary flow rate of the submandibular/sublingual complex, but it seems to be a poor methodwhen used alone.37 Hearing loss is a possible complica-tion. This method would thus be contraindicated inpatients who already have hearing problems, exceptfor those with total hearing loss. Since chorda tympanineurectomy always produces a loss of taste in the ante-rior two thirds of the tongue,38 it seems unethical to takeaway the enjoyment of taste from neurologically de-fenseless patients who have so few pleasures in life,just to control drooling.39

Despite an initially high success rate, the long-termresults of neurectomies used alone are relatively dis-appointing.40 Besides, it must be stressed that droolingis not hypersalivation; neurectomies do not directlycorrect the cause.

Salivary duct and gland procedures. Table II summa-rizes the success and major complications of salivaryduct and gland procedures. 41,5,42-65 One of the earliestreports on surgical management of drooling concernedbilateral parotid duct relocation from the buccal vesti-bule in the area of the maxillary secondmolar to the ton-sillar fossa, or the posterior part of the tonsillar pillar, toinitiate the swallowing reflex, accompanied by bilateralsubmandibular sialoadenectomy.66 Bilateral duct liga-tion of the parotid glands combined with submandibulargland removal has been proposed as a simpler procedurewith good outcome (85%-86% success) in 3 studies total-ing 96 patients.43,47,49 The purpose of duct ligation is toobtain gland atrophy.

Submandibular duct relocation performed alone or incombination is a common procedure. The success ratehas been good in all reported studies, ranging from75% to 89%. This technique offers the following advan-tages: scarless procedure, relatively low complicationrate, potential reversibility, and the physiological fea-tures. Saliva, in contact with the base of tongue, can ini-tiate a swallowing reflex.Manymodifications have beenadvocated. Ekedahl41 reported the combination of sub-mandibular duct relocation with sublingual duct liga-tion. Adam et al.67 associated relocation of bothparotid ducts for the treatment of 3 drooling children.After an experimental study,68 Ozgenel and Ozcan69 as-sociated bilateral parotid-duct diversion using autolo-gous venous grafts in order to eliminate the risk ofductal stenosis. Wilson and Henderson coupled the sur-gical procedure with unilateral parotid duct ligation.59

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Excision of sublingual glands at the same time reducesthe occurrence of ranula.61 Tonsillectomy can be indi-cated to reduce the risk of obstruction of the relocatedducts. Attention must be paid to a potential increase ofcaries in the mandibular incisal and canine area.70,71

Klem and Mair72 advocated a technique consisting ofligation of both the parotid and submandibular ducts.Their success rate was 100% in 5 patients, without anymajor complications. With a larger case series, Shirleyet al.65 reported a success rate of 81% with this verysimple procedure.

Submandibular duct relocation seems to be the phys-iological procedure to initiate the swallowing reflex. Inpatients with a history of aspiration pneumonia, proce-dures that decrease salivary output, are more advisable.

Minimally invasive methods for treatingdrooling problems

Injection of botulinum toxin. The more significantstudies on botulinum toxin serotype A in the treatmentof drooling are gathered in Table III.73-86,4,87-89

Xerostomia is one of the first manifestations of botu-lism. This led the medical community to investigatean application to sialorrhea and drooling.

When injected in the salivary gland, botulinum toxinserotype A (BTX/A) inhibits acetylcholine release inthe cholinergic nerve endings, mainly at neurosecretoryjunctions. The BTX/A binds to a protein called SNAP-25, forming a complex that impairs neuronal exocytosisby inhibiting fusion of the presynaptic vesicles contain-ing the neurotransmitter.90 An initial animal modelshowed a significant reduction in saliva productionwithout direct toxicity to the acinar cells.91 Althoughonly pilot studies with relatively small groups of pa-tients are available (Table III), it is interesting to con-sider that the outcome is uniformly favorable, withvery rare reports of serious complications. Up to twothirds of patients experienced a marked or moderateimprovement of drooling after the treatment of bothparotid glands or parotid and submandibular glandscombined. The injection is made percutaneously, andultrasound guidance improves efficacy and safety.85,87

For young children, general anesthesia may be neces-sary. Transductal injection is not recommended.92 Theparotid gland is usually injected at 2 or 3 sites, andthe submandibular gland at 1 to 3 sites. Generally, theduration of action varies from 6 weeks to 6 months.The reported side effects include weakness of adjacentmuscles producing difficulty of chewing and swallow-ing due to BTX diffusion into masseter or pharyngealmuscles, risk of aspiration, facial weakness, and localinfection. Other potential side effects are hematoma,salivary duct calculi, local injuries of the carotid arteriesor branches of the facial nerve, and recurrent jaw

dislocation.93 A randomized controlled trial84 testing3 different doses of BTX/A stressed the fact that higherdoses reduce drooling more, but the highest safe dose isstill unknown. Besides, we do not know the effect of re-peated injections of BTX/A over time, or the risk of de-veloping antibodies.

Botulinum toxin serotype B (BTX/B) displays differ-ent pharmacological properties than type A; successhas also been documented in drooling patients withParkinson’s disease.94,95

Photocoagulation of salivary ducts. With the aim tominimize surgical complications, Chang and Wong96

used Nd:YAG laser (1064 nm) for intraductal laserphotocoagulation of bilateral parotid ducts, at 7 or 10watts during 10 seconds, in 48 cerebral-palsied patients.Under general anesthesia, operating time ranged from25 to 65 minutes. The concepts of laser-tissue interac-tion of intraductal laser photocoagulation are based onpartial destruction of the parotid gland and occlusionof the parotid ducts. Significant improvement in drool-ing severity and frequencywas measured in the majorityof cases. Postoperatively, transient facial swelling wasseen in all patients. The complications were 1 hema-toma, 2 infections, and 2 cystic formations. Moreover,laser photocoagulation of submandibular ducts may beindicated in individuals with poor results or recurrentdrooling. This technique is a simple and effective mo-dality for reducing drooling in cerebral-palsied patients,but its objective is to decrease saliva flow leading to thementioned complications.

Tongue acupuncture. Based on a cohort study, Wonget al.97 assessed daily tongue acupuncture applied to 5specific acupoints for the treatment of drooling in 10children with severe physical and/or cognitive disabilityand who were unable to comply with a formal behav-ioral modification program or oral-motor training pro-gram. Thirty sessions were administered. The authorshypothesized that acupuncture would stimulate therich neural network in the tongue, which is connectedto salivary glands and tongue muscles via the cranialnerve nuclei, and improve salivary secretion and swal-lowing mechanisms. Children easily tolerated the treat-ment with significant improvement of drooling and nocomplication. This technique may be an alternative oradjunctive option for children with intractable drooling.However, the technical skill and experience of thepractitioners is a marked obstacle for this technique.Besides, larger case series with longer follow-up andquantitative assessment are expected.

Optimal treatmentThe physician may feel disoriented with, on the one

hand, so many causes of drooling with very differentpathogenic mechanisms, and on the other hand, so

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Table III. Studies on botulinum toxin serotype A (BTX/A) in the treatment of drooling

Reference (yr) No. patients Diagnosis

BTX/A dose

(mouse unit)

Sites of

injection Technique

Bhatia et al. (1999)73 4 PD1, PSP1, Dy1,

MND1

10 or 20 (Dysport) Each parotid Blind

Jost (1999)74 5 PD5 10 (BOTOX) Each parotid Blind

Pal et al. (2000)75 9 PD9 7.5-15.5 (BOTOX) Each parotid Blind

Giess et al. (2000)76 5 MND5 6-20 (BOTOX) Each parotid Blind

5 (BOTOX) Each

submandibular

Porta et al. (2001)77 10 MND4, PD2,

CP1, PT1, PS1,

SSPE1

15-40 (BOTOX) Each parotid US

10-15 (BOTOX) Each

submandibular

Jongerius et (2001)78 3 CP3 15, 20 and 25 U

(BOTOX)

Each

submandibular

US

Friedman and Potulska (2001)79 11 PD11 5 (BOTOX) Each parotid Blind

Suskind and Tilton (2002)80 22 CP22 (children) 20-40 (BOTOX) Parotid US

10-30 (BOTOX) Submandibular

Bothwell et al. (2002)81 9 CP, neuro

deficits (children)

5 (not specified) Each parotid Blind

Ellies et al. (2002)82 4 CA2, stroke1, PS1 55-65 (BOTOX)

in total

Parotid,

submandibular

US

Ellies et al. (2003)83 13 CA8,

neurodegenerative

4, stroke1

22.5 (BOTOX) Each parotid US

10 (BOTOX) Each

submandibular

Lipp et al. (2003)84 32 ALS12, PD12,

MSA4,

corticobasal

degeneration 4

18.75, 37.5, 75

(BOTOX) – dose-

effectiveness

analysis

Each parotid Blind

Mancini et al. (2003)85 20 double-blind,

placebo-controlled

PD14 (idiopathic)

MSA6

150 (Dysport) Each parotid US

75 (Dysport) Each

submandibular

Kahl et al. (2004)86 1 Clozapine1 150 IU (not

specified)

Each parotid Not specified

Jongerius et al. (2004)4 45 controlled clinical

trial

CP45 (children) 15, 20 and 25

(BOTOX)

Each

submandibular

US

Dogu et al. (2004)87 15 PD15 15 (BOTOX) Each parotid Blind/US -

technique analysis

Hassin-Baer (2004)88 9 CP6, other

neurologic

disorders 3

10-25 (BOTOX) Each parotid US

Savarese (2004)89 21 CP21 15 (BOTOX) Each parotid Blind (but with

electromyographic

needle)

One mouse unit of BOTOX is equivalent to ;2.5 to 4 units of Dysport.

CA, carcinoma; CP, cerebral palsy; CZP, clozapine-induced hypersalivation; Dy, dystonia; MND, motor neuron disease; MSA, multiple system atrophy;

PD, Parkinson’s disease; PS, primary sialorrhea; PSP, progressive supranuclear palsy; PT, post traumatic encephalopathy; SSPE, subacute sclerosing

panencephalitis; US, ultrasound.

many treatments available. Nevertheless, bearing inmind just a few therapeutic recommendations is suffi-cient to help most patients.

The first step is to correct the many situational factorsthat may worsen the drooling of the patient, such as ab-normal head position, airway problems, unnecessary

medications, severemalocclusion, and significant dentaldisease, and better yet, if possible, to correct the cause.98

Thereafter, it is important, whenever feasible, to pro-pose the more physiological treatments like oral motortherapy, behavior modification, or orofacial regulationtherapy. When this is impossible, unsuccessful, or not

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sufficient, it is suitable to propose drug therapy. Whenthese means have proven ineffective, more aggressivetreatments are indicated, giving preference to the morereversible treatments like botulinum toxin. Whensurgical management is required, preference should beplaced on the more conservative and physiological ap-proaches such as rerouting the submandibular ducts. Ifthe patient has a short life expectancy, more aggressivetreatment such as radiotherapy or four-duct ligationmaybe indicated, dependingupon the specific clinical sta-tus of the affected individual and the severity of theproblem.

Whatever the chosen treatment, it is mandatory tomaintain regular oral examinations to prevent or to treatcomplications related to decreased salivation.

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Reprint requests:

Jean-Paul Meningaud, MD, PhD

Service de Chirurgie Maxillo-Faciale

CHU Pitie-Salpetriere

47, Bd de l’Hopital

75651 Paris cedex 13, France

[email protected]

mailto:[email protected]