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Sialorrhea
Excessive Drooling in Children with Disabilities

Sialorrhea, or excessive drooling, is a common problem found in children with neurological impairments. Cerebral palsy is found to be the most common disorder associated with drooling. Drooling beyond the age of 4 years is considered abnormal and can cause significant problems including aspiration, infection, increased amount of care required for the child (changing bibs, bathing), soiling of furniture, carpet, toys, and clothing of siblings and family members, minor to major skin irritations, and difficulty with social interactions and developing relationships.

It is said that drooling is caused by: a defect in the oral or voluntary phase of swallowing, resulting in a buildup of saliva in the front of the mouth; poor head control; constant open mouth; poor lip control; or decreased tactile sensation. In addition, adverse drug reactions involving tranquilizers and anticonvulsants can cause hypersecretion of saliva. Although drool can be very undesirable for the parents and others involved in the care of the child, saliva, itself, has several specific and important functions: it lubricates food for swallowing; it helps in the digestion of starch; it is crucial for oral hygiene; it maintains tooth structure and integrity; and it has various immunologic and nonimmunologic proteins that destroy intra-oral bacteria. Therefore, if you are considering a saliva treatment, it is important that the advantages outweigh the disadvantages of decreasing saliva in the mouth. More specifically, whatever saliva management method is chosen, it is important that the mouth be kept moist and prevented from becoming overly dry.

The management of sialorrhea is usually based on a team approach including an otolaryngologist, a speech pathologist, and a dentist. The speech pathologist determines the probability of improvement of oral-motor skills with time, therapy, or both. The dentist assesses structural abnormalities and health of the teeth and gums. The otolaryngologist examines for head and neck pathology, looks for upper airway obstruction, and determines the severity of the drooling problem. Once the team has evaluated the child, the type of treatment to be used is decided, however, it typically consists of a combination approach. The current treatments available are behavioral therapy, oral-motor therapy, medication, and surgery. Speech therapy and behavior modification techniques are said to show only modest improvements and do not have long-term effects, whereas, medications and surgery have a much higher rate of success.

Medications used for managing sialorrhea work by drying up the secretions, however, their use often results in a dry mouth, causing swallowing difficulties and poor oral hygiene. These drugs most often contain atropine sulfate, scopolamine, or glycopyrrolate, which, in themselves, are used to treat a variety of different conditions. While these medications have been shown to decrease the amount of saliva production, they have side-effects that should be given great consideration before the decision is made to begin using medication as a method to control drooling.

Atropine sulfate (Sal-tropine) is used to reduce salivation and bronchial secretions as well as to help pylorospasm and other spastic conditions of the gastrointestinal tract. The side-effects of atropine sulfate vary depending on the dosage given. Side-effects of the dosage typically given to children includes dryness of the nose and mouth and bradycardia (slowing of the heart rate). In addition, atropine sulfate is known to mildly stimulate the Central Nervous System (CNS), therefore, it should not be taken with other medications that also affect the CNS. This drug should not be used for individuals with glaucoma, adhesions between the iris and lens of the eye, or asthma.

Scopolamine (which comes in a patch that is applied to the skin behind the ear and in tablet form), is typically used to prevent nausea and vomiting associated with motion sickness. It has common side-effects which include dry mouth, drowsiness, and constipation. This drug should be used with extreme caution for those with pyloric, bladder, or intestinal obstruction, impaired metabolic, liver, or kidney functions, or a history of seizures. In addition, scopolamine should not be taken with any other medications that may affect the CNS. In some cases, symptoms such as dizziness, vomiting, nausea, headache, and disturbances of the equilibrium have been reported by some people following the discontinuation of the patch. Although some physicians have prescribed this medication to control drooling in children, the manufacturer strongly recommends that scopolamine not be used with children, as the safety of its use in children has not been determined and it is not known whether the patch will release an amount of scopolamine that could produce serious adverse effects. If scopolamine is the physician’s choice of medication, it is recommended that a low dose tablet is used because it allows physicians and parents the opportunity to adjust the dose to the lowest level to best meet each patient's needs. Furthermore, scopolamine tablets are associated with fewer side-effects compared with the topical medication.

Glycopyrrolate (Robinul) is used to treat ulcers, reduce spasms of the digestive system, and reduce salivary secretions. The most common side-effects of this medication are dry mouth and constipation. Less common symptoms include rapid heartbeat and decreased sweating. This medication should not be taken with any other medications that may affect the CNS or if the individual has stomach bloating, severe ulcerative colitis, narrow-angle glaucoma, difficulty emptying bladder completely, or obstructive disease of the gastrointestinal tract.

There are several surgical approaches to managing sialorrhea in individuals with disabilities. The surgical procedure most often used, bilateral submandibular ducts relocation (SMDR), redirects the flow of saliva from entering the oral cavity in the front of the mouth, to entering in the back portion of the mouth. Therefore, the saliva that would typically pool and then spill out of the mouth is instead in the back of the mouth and swallowed. Of course, a requirement of this procedure is that the individual is able to swallow the saliva when it enters the back portion of the mouth. One of the benefits of this surgery is that the procedure is done on the inside of the mouth so there is no external incision. The success rate is 80%.

Another type of surgery performed is the removal of the submandibular gland in the upper portion of the neck. The advantage of this surgery is that the source which is producing the saliva is removed. The disadvantages are that there is an external incision, potential nerve injury, and dry mouth (which increases the risk of cavities and can cause difficulty in swallowing).

A third available surgery involves closing the parotid duct inside the oral cavity. For individuals who produce thin saliva, this procedure is very effective and does not require an external incision. The disadvantage to this procedure is that there can be significant cheek swelling for a few days following the procedure.

Excessive drooling can be a very significant problem for the child with disabilities and his or her family members. While the elimination of the drool would be a desirable outcome, the process to do this is not always beneficial. Medications have side-effects and surgeries are not always successful or can lead to other problems. If you are considering a treatment method for your child, be sure to discuss all your options with your child’s physician and ensure that the benefits of the management plan outweigh the risks.

For more information on sialorrhea and the products used to manage it, please visit the following web sites:

 

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