Drooling

What is drooling (sialorrhoea)?

Drooling (also called dribbling) is the unintentional loss of saliva from the mouth and for some people it can become a major issue. It may be an issue for some patients with facial palsy where the lips are weak and do not seal when the mouth is closed. People with Moebius syndrome often suffer with excessive drooling due to other cranial nerve involvement. Drooling is rarely caused by an excess production of saliva. It often occurs as a result of an inefficient, uncoordinated or infrequent swallow.

Drooling is normal in young infants regardless of whether they have facial palsy or not. It usually stops during the daytime by the time a child is aged 4, or older children may drool while sleeping. Drooling often happens at night and can also be related to sleep posture.

There are some medical treatments which can help with excessive drooling and patients should speak to a health professional about which option is best for them. There are side effects with drug treatments which should be discussed with your doctor if you have any concerns, especially as patients with facial palsy may have a combination of dry mouth and drooling. Professionals you could ask to be referred to about drooling are Speech and Language Therapist or ENT (Ear, Nose and Throat) specialist.

It is important to assess and treat any dental issues as saliva has an important role in protecting the teeth.

Treatments that may help

Glycopyrronium bromide

This medicine is used for the symptomatic treatment of severe drooling. This is currently the first-line treatment used for drooling at Alder Hey Children’s Hospital.

NICE information

Hyoscine Patches

In the UK, hyoscine hydrobromide (scopolamine hydrobromide) is available over the counter for travel sickness. It is available as injections, tablets (eg. Kwells), chewable tablets (eg. Joy-rides) and as a transdermal patch that delivers the drug through the skin. None of these are licensed to treat hypersalivation (drooling).

The transdermal patches offer an easy method of administration together with a steady level of the drug in the blood stream and a low incidence of systemic side effects compared to other similar drugs. A number of studies have demonstrated a reduction of saliva production in children and adults but all were short term and therefore could not provide long-term safety and efficacy data. The patches have been found to work for some people better than others. Long-term side effects may include the consequences of a dry mouth such as mouth infections (e.g. thrush), dental decay and swallowing difficulties. Clinicians should be aware of these side effects and monitor for them. Sometimes people can get skin reactions to the patches, please report any problems to your health care provider.

Anecdotal experience with this has been positive. Most patients (adults) are treated with one patch at a time, typically placed behind the ear and changed roughly every three days. In children, the patch may be cut into half or thirds to reduce the dosage.

This information does not replace that provided by your doctor and administration of this drug for hypersalivation should be performed under medical direction.

Some patients have reported being unable to get the patches due to supply problems.

NICE information

Botulinum Toxin (commonly known as Botox®)

Saliva glands function when nerves release a chemical messenger called acetylcholine at the junction where the nerve endings and saliva gland meet. Botox injections prevent the release of the chemical messenger blocking the function of the saliva gland and reducing saliva production. This is known as ultrasound-guided Botox therapy.

Other options are normally explored before Botox therapy is considered such as the medicines mentioned above. Generally the patient would need to be drooling constantly or unable to manage their secretions creating a risk of aspiration, before injections were considered. Botox therapy would not normally be offered if the patient only has problems with saliva overnight.

Use of Botox to treat drooling is often managed by ENT or Maxillofacial surgeons rather than a facial palsy specialist.

Drooling and synkinesis

A lot of patients with synkinesis experience minor drooling (dribbling) when they eat and drink or try to rinse their mouth. This can also be improved by targeted specialist facial therapy and Botox injections which target the tight muscles that pull down the corner of the mouth, making dribbling more likely. Releasing and reducing the overactivity of these muscles can improve oral competence and therefore confidence.

Self-help measures

Drooling is more noticeable when the head is forward and down, as gravity takes the flow of saliva to the front of the mouth which then leaks out the weakest part of the lips.

The following strategies may help:

• Sipping water can help you remember to swallow more frequently.
• To prevent saliva building up in your mouth, try and remember to swallow more frequently.
• A speech and language therapist or specialist facial therapist with experience in facial palsy may prescribe lip strengthening exercises to improve lip closure.
• Try and keep your head upright and avoid lowering your head or letting it drop forward. By looking down you will also have the effect of gravity to manage, so saliva can pool in the front of your mouth and leak out.
• Experiment with taping where you have severe cheek and lip weakness. You may find taping your cheek will give some support and comfort and could also reduce the amount of drooling.
• Try gently closing the teeth and suck the saliva back if you are out and about before any pools at the corner of your mouth and spills out.

Tips for managing drooling in children with facial palsy:

• Dab rather than wipe your child’s mouth and chin. Wiping across the mouth can cause more saliva to be produced.
• Children can wear a sweatband on their arm to discretely dab up saliva and have a secret code with a teacher/teacher’s aid where they can tap their shoulder and the child will know to dab their mouth.
• Avoid sweet and acidic foods as well as fizzy drinks as these increase saliva production.
• Encourage your child to have good posture as this can help to improve saliva control and reduce drooling.
• Help your child to become more aware when their face is wet or dry by talking about wet and dry.
• Seek a referral to a Speech and Language therapist if you are concerned about excessive drooling.