Drooling
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: ptyalism; sialorrhea; hypersalivation; Polysialia; Salivation excessive; Salivary hypersecretion; Sialism
Overview
Drooling is the uncontrollable flow of saliva outside the mouth. It can occur in either some nervous system disorders or anatomic abnormalities of the oral cavity. Either the production of saliva is excessive, the musculature of the mouth which normally controls the oral opening, is weak and not functioning to the adequate strength to help keep the saliva inside or there is difficulty in swallowing.
Firstly we will discuss the production of saliva, which is carried out by the salivary glands. Upon receiving the excitatory stimulus from salivary nuclei present in the brain stem, saliva is produced, which occurs in response to the taste, and visual stimuli received from the tongue and other parts of the mouth. These are categorized into minor and major salivary glands. The major glands, which are most impressive are present in the base of the mouth, front of teeth, and in the cheeks, known as submandibular, parotid, and sublingual glands. So in total, there are 6 major glands that secrete saliva.
Isolated drooling is a common phenomenon in babies, often associated with teething, but it usually stops at around 15-36 months, when the baby develops salivary continence. Drooling in infants and young children may be exacerbated by upper respiratory infections and nasal allergies. The persistence of Sialorrhea after 4 years of age is therefore considered pathologic at times. It may persist due to hyper-salivation, or neurologic disorders like cerebral palsy, Parkinson’s disease, and amyotrophic lateral sclerosis, or as a side effect of medications. The most common cause of sialorrhea in children is Cerebral palsy whereas, in adults, Parkinson's disease is the most common cause. Other contributing factors for drooling are dental malocclusion, postural issues, and an inability to recognize salivary spills.
Drooling associated with fever or trouble swallowing may be a sign of a more serious disease including:
- Retropharyngeal abscess
- Peritonsillar abscess
- Tonsilitis
- Mononucleosis
- Strep throat
- Parkinson's disease
Sudden onset drooling may be an indication of poisoning (predominantly by pesticides) or a reaction to snake or insect venom. It can also be a side effect of numbed mouth from either orajel use in the dentist's office or medications. Some neurological problems also cause drooling. Excess intake of Capsaicin can lead to drooling as well, an example being the ingestion of particularly high Scoville Unit chili peppers.
Seasonal Allergies from pollen, trees, grass, mold, and weeds can also cause excessive saliva production and be a cause for drooling. Another form of ptyalism is associated with pregnancy, most common in women with a condition known as Hyperemesis Gravidarium, or uncontrollable and frequent nausea and vomiting during pregnancy which is far worse than typical "morning sickness". With Hyperemesis, ptyalism is a side-effect, which is a natural response to uncontrollable vomiting. With normal vomiting, salivary glands are stimulated to lubricate the esophagus and mouth to aid in expelling stomach contents. During a hyperemesis pregnancy, many women complain of excessive saliva and an inability to swallow this saliva. Some women note-having to carry around a "spitoon" or using a cup to spit. Swallowing their own saliva has been noted to gag and further nauseate the women making the hyperemesis that much worse.
There are several theories as to the causes of hyperemesis and related symptoms such as ptyalism. Many physicians are reluctant to treat hyperemesis since they don't see it as a true physiological illness but rather "in the patient's mind" [note: this is an old fashioned view and the medical community now considers hyperemesis as a real and serious physiological condition]. Many pregnant women who suffer end up terminating the pregnancy. Others refuse to carry another child. The most frequent act is preparing for the onset of hyperemesis if a subsequent pregnancy is expected.
Drooling is very bothersome, and can lead to many complications, both physical and psychosocial. Maceration and infection of the skin around the mouth, halitosis, dehydration, abnormalities in speech, and feeding difficulties are some of the complications. Also, drooling increases the chances of aspiration of saliva, food, or fluids into the lungs, especially with deranged reflex mechanisms like gagging or coughing. Moreover, people suffering from this face psychosocial troubles like isolation, education difficulties, increased level of dependency, decreased self-esteem, and difficult socialization. This overall, sialorrhea has a significant negative impact on the quality of life.
Physiology
The major salivary glands in our oral cavity are the parotid, submandibular, and sublingual glands; amongst which the parotid glands are the largest. Saliva produced by these glands help in lubrication, and digestion of food, providing immunity, and maintaining of homeostasis in the human body. The salivary secretion is controlled mainly by the parasympathetic nervous system, with a minor contribution of sympathetic nervous system. The parasympathetic fibers originating from the pons and medulla, synapse in the otic and submandibular ganglia. The postganglionic fibers which originate from otic and submandibular ganglion regulate functions of parotid gland and submandibular/sublingual glands respectively. The sympathetic signals aid in contraction of muscle fibers surrounding the ducts of these glands, which result in the flow of saliva.
About 1.5 L of saliva is produced every day, 90% of which is carried out by the major salivary glands provide. Without stimulation, in the basal state, 70% of total saliva is produced by the submandibular and sublingual glands. Upon stimulation, the salivary secretion increases by five times. Chewing is an important source which causes stimulation of salivary glands. Salivary glands produce 2 types of saliva; thin and watery serous saliva, produced mainly by parotid glands and viscous thick saliva, produced predominantly by sublingual and submandibular glands. Excessive production of both can be a problema. Serous watery saliva consistently keeps on spilling from the side of the mouth, and viscous saliva being sticky, is harder to clear and often causes choking, which leads to panic.
Causes
Common Causes
- Retropharyngeal abscess
- Peritonsillar abscess
- Tonsilitis
- Mononucleosis
- Strep throat
- Parkinson's disease
- Epiglottitis
- Enlarged adenoids
- Dentures that are new or don't fit well
- Bell's palsy
- Cerebral Palsy
Causes by Organ System
| Cardiovascular | No underlying causes |
| Chemical / poisoning | Mexican tea poisoning , Mercury poisoning , Mayapple poisoning , Marsh marigold poisoning , Jonquil poisoning , Jessamine poisoning
Copper , Buttercup poisoning , Bush lily poisoning , Balsam apple poisoning , Arsenic poisoning , Antimony , Amaryllis poisoning, Achillea ptarmica |
| Dermatologic | No underlying causes |
| Drug Side Effect | Voriconazole , Radiation Therapy, Pyridostigmine , Procyclidine , Potassium Chlorate, Pilocarpine, Nicotine nasal spray , Loratadine , Iodide, Galantamine , Donepezil, Clozapine (Clozaril), clonazepam (Klonopin), Clobazam, carbidopa-levodopa, Bromide, Flurazepam, Loxapine |
| Ear Nose Throat | Swollen adenoids , Strep throat , Retropharyngeal Abscess , Peritonsillar abscess , Epiglottitis , Enlarged adenoids |
| Endocrine | No underlying causes |
| Environmental | No underlying causes |
| Gastroenterologic | Stomatitis , Sialorrhea , Pancreatitis , Oral suppurative lesions, Oral infectious Lesions , Oral chemical burns , Motion sickness , Macroglossia, Liver disease , Heartburn or GERD (reflux) , Gastroesophageal Reflux , Gastric distention or irritation , Esophageal food bolus obstruction , Esophageal atresia , Endoscopic foreign body retrieval , Aphthous Ulcers , Acute Gastritis or Gastric Ulcer |
| Genetic | Fragile X syndrome , Down syndrome, Autism |
| Hematologic | No underlying causes |
| Iatrogenic | No underlying causes |
| Infectious Disease | Tuberculosis , Tonsillitis , Syphilis, Small Pox , Sinus infections ,Rabies , Mumps, Mononucleosis , Infection in your mouth or throat , Foot-and-mouth disease , Diphtheria , Chronic sinusitis , Chancre , Botulism , Boston Ivy poisoning , Alveolar abscess , Acute sinusitis , Actinomycosis |
| Musculoskeletal / Ortho | Sarcoma of the jaw , Jaw Fracture or dislocation , Bone Lesions , Ankylosis of the Temporomandibular Joint |
| Neurologic | Tonic-Clonic seizure , Tonic seizure , Stroke , Spastic paraplegia , Rolandic Epilepsy , Right parietal lobe syndrome related Alzheimer's disease , Pseudobulbar paralysis , Parkinson disease , Myasthenia Gravis ,Multiple sclerosis , Mixed Cerebral Palsy , Microcephaly , Mental retardation , Juvenile Primary Lateral Sclerosis , Hypotonia , Hypoglossal Nerve palsy , Guillain-Barre syndrome , Familial dysautonomia , Epilepsy and Ataxia Syndrome , Dementia , Cerebrovascular Accident , Cerebral Palsy, Bulbar Paralysis , Bilateral Facial Nerve Palsy , Bell's palsy , Athetoid Cerebral Palsy , Amyotrophic lateral sclerosis |
| Nutritional / Metabolic | Excessive starch intake |
| Obstetric/Gynecologic | Pregnancy |
| Oncologic | Epulis |
| Opthalmologic | No underlying causes |
| Overdose / Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | No underlying causes |
| Renal / Electrolyte | No underlying causes |
| Rheum / Immune / Allergy | No underlying causes |
| Sexual | No underlying causes |
| Trauma | No underlying causes |
| Urologic | No underlying causes |
| Dental | No underlying causes |
| Miscellaneous | Smith-Magenis Syndrome , Segawa syndrome , autosomal recessive , Schwartz-Jampel Syndrome , Pregnancy , Mobius syndrome , Hyperemesis Gravidarum , Foix-Chavany-Marie syndrome , Dog odor , Dentures that are new or don't fit well , Dental malocclusion , Dental implant , Dental Caries , Cantharides , Angelman-Like Syndrome , Allergies |
Causes in Alphabetical Order
- Acute Gastritis or Gastric Ulcer
- Alveolar abscess
- Amaryllis poisoning
- Angelman-Like Syndrome
- Ankylosis of the Temporomandibular Joint
- Aphthous Ulcers
- Athetoid Cerebral Palsy
- Balsam apple poisoning
- Bilateral Facial Nerve Palsy
- Bone Lesions
- Boston Ivy poisoning
- Bulbar Paralysis
- Bush lily poisoning
- Buttercup poisoning
- Cantharides
- carbidopa-levodopa
- clonazepam (Klonopin)
- Clozapine (Clozaril
- Dental Caries
- Dental malocclusion
- Dentures that are new or don't fit well
- Epilepsy and Ataxia Syndrome
- Excessive starch intake
- Gastric distention or irritation
- Gastroesophageal Reflux
- Heartburn or GERD (reflux)
- Infection in your mouth or throat
- Jaw Fracture or dislocation
- Jessamine poisoning
- Jonquil poisoning
- Marsh marigold poisoning
- Mexican tea poisoning
- Mixed Cerebral Palsy
- Mountain Laurel poisoning
- Oral chemical burns
- Oral infectious Lesions
- Oral suppurative lesions
- Organophosphate insecticide poisoning
- Poisoning (pesticides)
- Potassium Chlorate
- Radiation Therapy
- Rattlesnake bite
- Reaction to snake or insect venom
- Retropharyngeal Abscess
- Right parietal lobe syndrome related Alzheimer's disease
- Rolandic Epilepsy
- Sarcoma of the jaw
- Schwartz-Jampel Syndrome
- Sea urchin poisoning
- Segawa syndrome, autosomal recessive
- Sialorrhea
- Sinus infections
- Skunk cabbage poisoning
- Small Pox
- Smith-Magenis Syndrome
- Split-leaf philodendron poisoning
- Swollen adenoids
- Tonic seizure
- Tonic-Clonic seizure
- X-linked Ataxia Telangiectasia
Ankylosis of the Temporomandibular Joint
Dentures that are new or don't fit well
Donepezil (patient information)
Endoscopic foreign body retrieval
Esophageal food bolus obstruction
Gastric distention or irritation
Infection in your mouth or throat
Juvenile Primary Lateral Sclerosis
Organophosphate insecticide poisoning
Reaction to snake or insect venom
Right parietal lobe syndrome related Alzheimer's disease
Segawa syndrome, autosomal recessive
Split-leaf philodendron poisoning
X-linked Ataxia Telangiectasia
Management
Sialorrhea is best managed by a team of primary health care providers, speech therapists, occupational therapists, dentists, orthodontists, neurologists, orthodontists, and otolaryngologists. Treatment options available for drooling can be either conservative, including just observation, some postural modifications, or biofeedback to more aggressive options like medication, radiation, or even surgical therapy. Anticholinergic medications, like glycopyrrolate or scopolamine, effectively reduce drooling, with certain side effects. The injection of botulinum toxin type A into the parotid and submandibular glands is another safe yet effective method of controlling drooling, but the effects fade in some months and we need to do repeat injections. Surgical interventions, like salivary gland excision, or duct ligation, and rerouting, are the most effective and permanent treatment options which greatly improve the quality of life of patients.
Home care
Care for drooling due to teething includes good oral hygiene. Ice pops or other cold objects (e.g., frozen bagels) may be helpful. Care must be taken to avoid choking when a child uses any of these objects.
Drooling also is common in children with neurological disorders and those with undiagnosed developmental delay.
- lack of awareness of the build-up of saliva in the mouth,
- infrequent swallowing,
- inefficient swallowing.
- increased awareness of the mouth and its functions,
- increased frequency of swallowing,
- increased swallowing skill.
Sialorrhea
Sialorrhea is a condition characterized by the secretion of drool in the resting state. It is often the result of open-mouth posture from CNS depressants or sleeping on one's side. In the resting state, saliva may not build at the back of the throat, triggering the normal swallow reflex, thus allowing for the condition.
Treatment
A comprehensive treatment plan incorporates several stages of care: correction of reversible causes, behavior modification, medical treatment, and surgical procedures. Atropine sulfate tablets are indicated to reduce salivation and may be prescribed by doctors in conjunction with behaviour modification strategies. In general, surgical procedures are considered after evaluation of non-invasive treatment options.
External links
Template:Oral pathology
de:Hypersalivation
nl:Speekselvloed
fi:Kuolaaminen