Drooling

Aka: Drooling, Ptyalism, Ptyalorrhea, Sialism, Sialismus, Sialorrhea, Hypersalivation, Hyperptyalism, Excessive Salivation

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II. Pathophysiology

  1. Normal Submandibular Saliva production 0.10-0.15 ml/min
  2. Ptyalism may result in 1-2 L/day of Saliva loss
  3. Mechanisms of excessive Saliva
    1. Decreased saliva Swallowing and clearance
    2. Excessive Saliva production
    3. Neuromuscular disease
    4. Anatomic abnormalities

III. Causes: Saliva Overproduction

  1. Pregnancy (Ptyalism Gravidarum)
    1. Hyperemesis Gravidarum
  2. Excessive starch intake
  3. Gastrointestinal causes
    1. Gastric distention or irritation
    2. Gastroesophageal Reflux
    3. Acute Gastritis or Gastric Ulcer
    4. Pancreatitis
    5. Liver disease (including Hepatic Encephalopathy)
  4. Medications and toxins
    1. Clozapine (Clozaril)
    2. Potassium Chlorate
    3. Pilocarpine
    4. Mercury Poisoning
    5. Copper
    6. Arsenic Poisoning
    7. Antimony (used to treat Parasitic Infections)
    8. Iodide
    9. Bromide
    10. Aconite (derived from Aconitum napellus root)
    11. Cantharides
  5. Stomatitis and localized Oral Lesions
    1. Aphthous Ulcers
    2. Oral Chemical Burns
    3. Oral suppurative lesions
    4. Alveolar abscess
    5. Epulis
  6. Oral infectious Lesions
    1. Dental Caries
    2. Diphtheria
    3. Syphilis
    4. Tuberculosis
    5. Small Pox

IV. Causes: Difficulty SwallowingSaliva

  1. Infections
    1. Tonsillitis
    2. Retropharyngeal Abscess
    3. Peritonsillar Abscess
    4. Epiglottitis
    5. Mumps
    6. Chancre
    7. Actinomycosis
  2. Bone Lesions
    1. Jaw Fracture or dislocation
    2. Ankylosis of the Temporomandibular Joint
    3. Sarcoma of the jaw
  3. Neuromuscular disorders
    1. Cerebral Palsy
    2. Mental Retardation
    3. Bulbar Paralysis
    4. Pseudobulbar paralysis
    5. Bilateral Facial Nerve Palsy
    6. Cerebrovascular Accident
    7. Myasthenia Gravis
    8. Hepatic Encephalopathy
    9. Hypoglossal Nerve palsy
    10. Rabies
    11. Botulism
  4. Miscellaneous Causes
    1. Radiation Therapy
    2. Macroglossia
    3. Dental malocclusion

V. Management: Non-specific

  1. Treat specific causes as below
  2. General measures to reduce Saliva
    1. Tooth Brushing and mouthwash has drying effect
    2. Reduce starch intake from diet
  3. Orthodontic appliances that aid Swallowing
    1. Upper plate to cover Palate with movable beads
      1. Aids lip closure
      2. Directs Saliva toward pharynx
  4. Anticholinergic Medications (if refractory to above)
    1. Glycopyrrolate
      1. Adults: 0.5 to 2 mg PO qd to tid prn
      2. Children: 0.04 mg/kg PO qd to tid prn
      3. Mier (2000) Arch Pediatr Adolesc Med 154:1214-8 [PubMed]
    2. ScopolaminePatch 1.5 mg applied every 72 hours prn
      1. Lewis (1994) Dev Med Child Neurol 36:484-6 [PubMed]
  5. Advanced procedures in severe and refractory cases
    1. Botulinum Toxin A Salivary Gland injection
      1. Performed under Ultrasound guidance
      2. Porta (2001) Psychiatry 70:538-40 [PubMed]
    2. Radiation Therapy
      1. Borg (1998) Int J Radiat Oncol Biol Phys 41:1113-9 [PubMed]
    3. Surgery
      1. Submandibular Gland excision or duct relocation
      2. Parotid duct relocation or ligation
      3. Salivary denervation (transtympanic neurectomy)
      4. Crysdale (2001) Dev Med Child Neurol 43:379-83 [PubMed]

VI. Management: Specific measures

  1. Treat Nausea with Antiemetics
  2. Treat Gastroesophageal Reflux
  3. Neuromuscular causes
    1. Speech pathology (e.g. Swallowing mechanism)
    2. Occupational therapy (e.g. head-back Wheelchair)
    3. Neurology Consultation
    4. Biofeedback
  4. Oral diseases including dental malocclusion
    1. Dentist or orthodontist
  5. Macroglossia or Tonsillar Hypertrophy
    1. Otolaryngology

VII. References

  1. Freeman (1994) J Natl Med Assoc 86(9):704-8 [PubMed]
  2. Hockstein (2004) Am Fam Physician 69:2628-34 [PubMed]
  3. Mandel (1995) J Am Dent Assoc 126(11): 1537-41 [PubMed]

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