Mechanisms For Drooling Disturbance In Pd
Patient reports of too much saliva in my mouth suggest hypersalivation as a cause. However, saliva production appears unchanged or even depressed in PD, indicating excessive salivation is not a crucial factor.26,3840,4547
Decreased salivary flow may relate to dysautonomia in PD. Hyposecretion may arise from medications common in PD.20,21,36 Altered reaction to stimulation, from reduced olfactory and other sensory triggers, may also play a role.48 Hou et al49 conducted a fMRI investigation to examine basal ganglia functional connectivity in drug-naïve people with PD who did or did not drool. Those with sialorrhea showed significantly reduced functional connectivity of putamen within bilateral sensorimotor cortices, superior and inferior parietal lobules and areas in the right occipital and temporal lobes.
Eating And Swallowing Problems And Parkinsons
Research suggests that eating and swallowing difficulties affect about a 90% of all people with Parkinsons. The true figure may be even higher as some people do not report the problem to their health care team.
Swallowing is a motor function that includes three stages.
- The first stage is the oral phase: food is chewed and mixed with saliva to form a soft ball called bolus. The tongue then pushes the bolus to the back of the mouth, triggering the swallow reflex.
- The second stage is the pharyngeal phase: it is the involuntary closure of the larynx by the epiglottis and vocal cords, which temporarily inhibites breathing. These actions prevent food from going ‘down the wrong pipe’ into the trachea .
- The third stage is the esophageal phase: the bolus moves into the esophagus, the muscular tube that contracts to push the bolus into the stomach.
Unfortunately, many people with Parkinsons experience swallowing problems due to reduced control and muscle tone of the jaw, lips, tongue and throat muscles, especially in later stages of the condition. Eating and swallowing becomes slower and requires more effort.
People with Parkinsons are at particular risk of aspiration due to a delay in the triggering of their swallow reflex. This compromises the effectiveness of the airway protection while swallowing. This can lead to aspiration pneumonia due to a lack of coughing if food enters the windpipe, allowing food to reach the lungs unchecked.
Why Do Dementia Patients Hold Saliva In Their Mouth
A person with a dementia may have difficulty with some types of food and fluids. This can lead to them spitting out lumps or holding food in the mouth. Things that can help include: giving a soft, moist diet avoid hard, dry or fibrous foods that need a lot of chewing like steak, bacon and wheaten bread.
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What Foods Stimulate Saliva Production
To increase saliva, try tart foods and drinks, such as lemonade or cranberry juice. Very sweet foods and drinks may also help. Avoid acidic foods and drinks if you have a sore or tender mouth. Enjoy soothing frozen fruits, such as frozen whole grapes, banana pieces, melon balls, peach slices, or mandarin orange slices.
Treating Eating And Swallowing Difficulties
If you or someone you care for is experiencing difficulties with eating, swallowing or saliva control, the first step is to consult your doctor, who may refer you on to an SLT / SLP.
Your doctor may be able to adjust the timing and dose of medicines so that these are working well at mealtimes and so swallowing problems are better managed when eating. However, for some patients, medications do not affect the swallowing function.
Your doctor may also adjust your medications, or may prescribe new ones to reduce production of saliva. Some Parkinsons medicines, including levodopa, improve muscle movement and may help to reduce drooling. However, some medications, such as clozapine, which is prescribed for mental health problems, can actually increase saliva production.
Anticholinergic medications may help to reduce the amount of saliva you produce but are not suitable for everyone. For more information see Managing medication.
Botulinum toxin can be injected into the salivary glands to reduce saliva production. This treatment will not work for everyone and injections may need to be repeated every three to six months. However, for some patients, Botox injections are not recommended and may be dangerous.
In severe cases when other treatments are not effective, radiotherapy to the salivary glands can restrict saliva production. In extreme cases the salivary glands can be surgically removed as a last resort.
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Why Does Parkinsons Disease Cause Drooling
Saliva is produced by small glands around our mouth, called Salivary glands.
It is a common misconception that Parkinsons patients have drooling because they are producing too much saliva. In fact, multiple studies have shown that most Parkinsons patients produce less saliva.
Our salivary glands continuously produce saliva, even when we are not eating.
Normally, we automatically swallow this saliva, through small gulps that we dont even notice.
But in Parkinsons disease, there is a marked decrease in all automatic movements, including automatic swallowing.
Therefore, saliva accumulates in the mouth. When the mouth is full, it drips out. We call this Drooling.
Lets talk about treatment
Management Of Saliva Flow
The British NICE guidelines for PD2 recommend referral to a speech-language clinician for assessment and treatment of drooling, though overall management is multidisciplinary. The guidelines advocate behavioral methods of intervention in the first instance, followed by consideration of pharmacological or surgical options if/when these are ineffective.
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Drooling In Parkinsons Disease: A Multifactorial Symptom
1Neuromuscular Rehabilitation Research Center, Semnan University of Medical Sciences, Semnan, Iran
2Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
3School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
How to Cite:BakhtiyariJ, MehriA, MaroufizadehS, AmanianH. Drooling in Parkinsonâs Disease: A Multifactorial Symptom,Arch Neurosci.2020 7:e99300. doi: 10.5812/ans.99300.
ARTICLE INFORMATION
Archives of Neuroscience:Article Type:
Objective Measures Of Flow/volume
Objective measurements of milliliters or milligrams secretion per minute typically center around gathering saliva at regular intervals over given time periods.68,69 Sampling methods include collecting saliva from cups placed over salivary ducts, expectoration into pots or tubes, weighing of gauze or cotton rolls held at given loci in the mouth, use of centrifuges to extract saliva from the gauze to quantify the volume of saliva absorbed or allowing saliva to dribble from the mouth with the head held forwards over receptacles.
As secretion is sensitive to a number of influences, gathering ideally occurs under controlled conditions. Posture is controlled the environment is quiet, with absence or minimization of visual, olfactory or gustatory stimuli known to prompt increased flow. Comparability of stimulated flow across patients and time demands use of standard stimulatory material and doses . To assure inter- and intra-individual comparability, evaluations ideally happen at the same time of day at the same point in the drug cycle in the same relationship to meal times . Onoff status and fluctuations need to be monitored as well as presence and severity of dyskinesias that may affect measurements.70
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Role Of Saliva In Health And Well
Two primary functions of saliva concern its role in maintaining oral pH and microbiotic homeostasis, and facilitating swallowing and speaking.46 Saliva possesses antimicrobial, anti-viral and anti-fungal properties which aid oral cleansing, protect against infection and support tissue repair it dilutes sugars and helps stabilize acidity it contributes to remineralization of dental enamel. It serves as a buffer for extremes of temperature or against noxious substances. It lubricates the oral cavity, thereby supporting formation and transport of the bolus to the pharynx. It acts as a first stage in digestion and stimulates interaction with chemosensory receptors to aid taste and smell perception. It supports smooth and accurate movement of the tongue and lips for speech.
A Reducing The Amount Of Saliva Produced:
Saliva can be reduced by a number of medications called Anticholinergics. These include medications such as Glycopyrollate, hycosamine etc.
These medications tell our salivary glands to decrease saliva production.
Some of these medications are also available in convenient packages such as skin patches. A Scopolamine patch is a small sticky patch applied to the skin. It gradually releases a medication called scopolamine. It needs to be replaced every 3 days.
Actually, I am not a big fan of these medications. Anticholinergics can produce some nasty side-effects such as confusion and urinary retention . Therefore, they need to be used carefully and at the lowest dose possible.
A much better alternative is botox injections into the salivary glands. These injections markedly decrease saliva production, reducing drooling dramatically in many cases.
Here is a link to one of the numerous research studies that have demonstrated the safety and efficacy of botox injections for excessive drooling in Parkinsons disease .
Botox injection into the salivary glands does not cause severe pain. It can be performed within a few minutes, in the outpatient department. There is no reason to get admitted.
Since such a small dose of botox is used, and very little of the botox goes into the bloodstream, there are usually no side-effects.
The only problems are that the injections are somewhat expensive & wear off after some time. They may need to be repeated every 3-6 months.
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What Are The Signs That A Person May Have Dysphagia
Other signs of dysphagia include: coughing or choking when eating or drinking. bringing food back up, sometimes through the nose. a sensation that food is stuck in your throat or chest. persistent drooling of saliva. being unable to chew food properly. a gurgly, wet-sounding voice when eating or drinking.
Is Drooling During Sleep Normal
In many cases, drooling during sleep is normal. Saliva production varies over the course of a day, perhaps according to a circadian rhythm. Although people generally produce more saliva during the day and less at night, saliva production continues during sleep. This saliva performs the important task of keeping your mouth and throat lubricated, which is required for good health. Continued saliva production during sleep makes drooling possible.
Although drooling while asleep is often normal, it might lead to unwanted consequences. For example, excessive drooling can cause chapping around the lips and mouth, bad breath, dehydration, and feelings of embarrassment.
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Symptoms Of Drooling In Older Adults
In older adults, frequent drooling can be a sign that your muscle control over your mouth and neck is weakening. When you drool, its often because you had more saliva in your mouth than you could control. Whether this is a problem with the lips, the throat, or something else can vary.
Other symptoms connected to drooling include:
Congestion
Nasal congestion may make it difficult to breathe through your nose, causing you to breathe through your mouth instead. If this is the case, you may find yourself drooling more frequently since your mouth is often open. This is likely a temporary type of drooling.
Snoring
Outside of acute congestion, its still possible for your breathing habits to cause drooling. People who snore or suffer from sleep apnea may find that they drool in their sleep more frequently than others. This is likely because they need to breathe through their mouth in their sleep.
Heartburn
If you experience heartburn, you may be more likely to drool. Gastroesophageal reflux disease often causes a symptom known as waterbrash, where your mouth suddenly fills with saliva. This sudden, unexpected saliva production may lead to drooling if youre speaking or eating.
Difficulty speaking
Normal Physiology Of Salivation And Swallowing
The processes of salivation are controlled by both sympathetic and parasympathetic nervous system. However, facilitation of ingestion and swallowing are mainly contributed by parasympathetic nervous system. The parasympathetic afferent pathways receive unconditioned reflex stimulation from the pharynx and esophagus. Then, signals are conducted via the vagus and spinal splanchnic nerves to the salivary center located in the medulla. The parasympathetic outputs are conducted via two different pathways including the glossopharyngeal nerve, which then innervates the otic ganglion, and, subsequently, to the parotid glands via the auriculotemporal nerve and the facial nerve through the chorda tympani nerve to the submandibular ganglia and then innervates the submandibular and sublingual glands via the lingual nerve .
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Managing Eating And Swallowing
It is important to continue eating normally as long as it is safe to do so. This will help to keep your muscles working, and maintaining a healthy diet is vital to good health . Only when eating and swallowing become significantly uncomfortable or difficult should you adapt your diet, for example by eating pureed foods.
Swallowing difficulties are individual and solutions vary from person to person, but the following tips on diet, drinking and eating techniques may help.
Prevalence Associated Factors And Negative Impacts Of Drooling In Pd
Due to the lack of a standard definition and criteria for diagnosing drooling in PD patients, estimates of prevalence vary. Previous studies showed that prevalence ranged from 10 to 84% . Various tools such as the Unified Parkinson’s Disease Rating Scale part II Scales for Outcomes in PD for Autonomic Symptoms PD non-motor symptoms questionnaire and different types of screening questionnaires were used to screen drooling. The factors associated with drooling have been reported. However, results vary among studies and the conclusion remains unclear. Factors possibly associated with drooling were severity of PD , male gender , aging , hallucinations , duration of PD , the sum of the scores of UPDRS part II and III greater than 28 points, dysarthria, dysphagia, orthostatic hypotension, and a history of using antidepressants . Drooling during PD can have negative impact for both patients and caregivers. Many negative physical sequelae were reported to follow the course of drooling such as perioral dermatitis, poor oral hygiene, bad breath, increased amount of intra-oral occult bacteria, eating and speaking difficulty, and an increased rate of respiratory tract infection from silent aspiration of saliva . Psychosocially, drooling PD patients showed poor quality of life , i.e., social embarrassment and increasing emotional distress . In addition, drooling patients affected their caregivers by increasing their burden, depression and anxiety, and reducing their QoL .
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Eating Swallowing Problems And Saliva Control
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Eating and swallowing problems, known as dysphagia, occur in many medical conditions and become more common as we get older.
The main risks associated with swallowing problems are:
- Choking or asphyxiation: When food blocks the airway, preventing breathing. Also, when food or liquid enter the airway below the level of the vocal cords.
- Aspiration pneumonia: When food or liquid enter the lungs, this may cause a lung infection.
- Increased secretion: As a reaction to food or liquid entering the lungs.
- Dehydration: Lack of fluids can lead to problems such as constipation.
- Malnutrition: Lack of nourishment leads to poor health and harms the bodys ability to fight infection.
- Drooling: decrease in mouth sensitivity and / or a reduction in the frequence of swallowing saliva can cause drooling.
- Difficulties in swallowing medications.
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Drooling In Seniors: What It Is Why It Happens How It Is Treated
Drooling is the unintentional spillage of saliva from the mouth. It occurs with any condition that impairs neuromuscular control of the muscles around the mouth. It is expected in babies, who do not yet have full motor control. But it is very embarrassing for senior citizens.
Drooling in the elderly is often associated with side effects of certain drugs and chronic conditions. It occurs when clearing saliva from the mouth is impaired.
Usually, seniors have difficulty keeping their lips pursed and also have trouble swallowing. The secretion of the salivary glands is controlled by the parasympathetic nervous system. When this system is stimulated, salivation increases. Neurological conditions and certain drugs can cause this reaction.
The most common causes are infections and neurological conditions.
Excessive drooling is common among people with:
- a history of traumatic brain injuries
- amyotrophic lateral sclerosis
- Parkinsons Disease
Other conditions that can lead to drooling include:
- Epiglottitis: This infection causes swelling of the epiglottis, a plate of cartilage in the back of the throat that helps a person to swallow.
- Bells palsy: This condition causes mild to severe muscle weakness on one side of the face.
- Guillain-Barré syndrome: This autoimmune disorder harms nerves throughout the body
This condition can have medical and psychosocial impacts on a persons life. It is also embarrassing in social situations and affects the self-esteem.
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Inflammation Of The Epiglottis
Epiglottitis is inflammation of the epiglottis, tissue that covers the trachea , which helps prevent coughing or choking after swallowing. It is usually caused by the bacteria H. Influenzae but can also be caused by other bacteria or viruses that cause upper respiratory infections.
Rarity: Rare
Top Symptoms: being severely ill, shortness of breath, fever, sore throat, pain with swallowing
Symptoms that never occur with inflammation of the epiglottis: cough
Urgency: Emergency medical service
Assessment Of Saliva Flow
Evaluation of saliva flow is challenged by a range of issues, including: difficulty obtaining objective measures in naturalistic settings time and place variability that exists in respect of natural variation in flow rates fluctuations in motor function experienced by pwPD that can impact on swallowing and saliva control the variety of situations across pwPD concerning where they experience difficulties or not and the subjective nature of whether an individual perceives there to be a problem present or not. Similar to other activity limitations in PD such as dysphagia and dysarthria, perceived magnitude of psychosocial impact of drooling, dry mouth and excess saliva does not necessarily correlate significantly with objective measures of saliva flow and loss.3,19,6567
These factors underline that no single assessment captures all dimensions important for establishing baseline and outcome measures of salivation/drooling. Accordingly, outcome evaluation covers a range of measurements, with a focus on key variables that encompass the patients own chosen concerns and goals.
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