What produces Excessive Saliva?

Causes

Excessive saliva can be caused by either an increase in your body’s production of saliva or a decrease in your ability to swallow or keep saliva in your mouth.

Causes of increased saliva production

Dentures that are new or don’t fit well
GERD (Gastroesophageal reflux disease)
Infection in your mouth or throat
Medications, such as clonazepam (Klonopin), clozapine (Clozaril, Fazaclo ODT), pilocarpine (Salagen) and carbidopa-levodopa (Parcopa, Sinemet)
Pregnancy
Stomatitis (inflammation of mucous membranes in your mouth)

Rarer causes of increased saliva production include:

Arsenic poisoning
Bell’s palsy (a condition that causes facial muscle weakness or paralysis)
Esophageal atresia (a disorder present at birth in which the esophagus doesn’t develop properly)
Mercury poisoning
Rabies (a deadly virus spread to people from the saliva of infected animals)
Syphilis (a bacterial infection usually spread by sexual contact)
Tuberculosis (an infectious disease that affects your lungs)

Causes of a decreased ability to swallow or to retain saliva in your mouth

Acute sinusitis
Allergies
Chronic sinusitis
Enlarged adenoids
Tumors that affect your tongue or lip movement

Conditions that affect your muscle coordination or the function of your oral cavity also may decrease your ability to swallow or to retain saliva in your mouth. These conditions include:

Amyotrophic lateral sclerosis (a neurological disease that causes muscle weakness)
Autism
Cerebral palsy (a disorder that affects your ability to coordinate body movements)
Dementia
Down syndrome
Fragile X syndrome (a form of inherited mental retardation)
Multiple sclerosis (a disease in which your body’s immune system attacks the sheath that covers your nerves)
Myasthenia gravis (a muscle weakness disorder)
Parkinson’s disease
Stroke

An increase in the amount of saliva in the mouth is a temporary problem and is usually not a cause for concern. Under normal circumstances, about 1 to 2 liters of saliva are produced by the salivary glands every day. We are usually aware of how we are constantly and unconsciously swallowing. If there is an excessive amount of saliva in the mouth, could mean that the salivary glands produce more saliva than normal. It is a condition known as sialorrhea. It could also mean that you can swallow less than usual.

The causes of excess production of saliva

Taking certain medications may result in excess saliva in the mouth. This condition is common during pregnancy, especially during the first quarter. A swallow may also contribute to a buildup of excess saliva in the mouth. These Swallowing problems may result in damage to the nerves or muscles of the throat and mouth. Other causes of excessive saliva production include the use of new dentures or those that do not fit properly to infections of the mouth, GERD or reflux, stomatitis with inflames the mucous membranes of the mouth, and childhood diseases. There are also some other causes of increased saliva. These cases are rare and are arsenic poisoning, mercury poisoning, esophageal atresia, a birth defect characterized by underdevelopment of the esophagus, Bell’s palsy, syphilis, tuberculosis, and rabies. Factors contributing to swallowing a person’s ability to affect the saliva include allergies, acute or chronic sinusitis, polyps, and tumors in the vicinity of swollen lips or tongue. If the coordination and functioning of the muscles in the oral cavity are affected, could lead to a decreased ability to swallow saliva.

Home Remedies for excessive salivation

Excess saliva in the mouth can be reduced by sucking on a lemon slice. This is known to regulate the amount of saliva in the mouth. Avoid eating too many sugary foods as sugar promotes increased production of saliva. The excess saliva can be absorbed by placing a pinch of ground coffee under the tongue. Another good remedy for excessive saliva in the mouth is sucking on a few sunflower seeds. This is also a benefit of repairing salivation during pregnancy. If this situation persists for a longer period of time or worsened is recommended that a medical examination because it may indicate a problem within the salivary glands suffer.

Possible causes of excessive saliva (please see your doctor about this):

–Seasonal allergies/flu

—-NEW DENTAL FILLINGS / DENTURES / ANYTHING PUT IN YOUR MOUTH BY DENTIST
Alzheimer’s Disease
Bell’s Palsy
Cyclic vomiting syndrome
Epiglottitis
Grand mal seizures
Motion sickness
Mouth conditions
Parkinson’s Disease
Pregnancy
Rabies
Sjogren’s Syndrome
Stroke
Wilson’s Disease

Excess saliva is also made when there is a problem in the mouth, such as an infection. People who read mystery novels know that too much saliva may be a sign of poisoning. Many poisons, including some mushrooms, arsenic, and mercury, can cause too much saliva. Medications such as pilocarpine (used to treat glaucoma and other eye problems) occasionally can cause this as well.

Sometimes, people make a normal amount of saliva but have a problem swallowing it. Infections such as strep throat, a throat abscess, or mumps can make swallowing difficult. Certain neurological diseases like Parkinson’s or stroke can do the same thing. People with these diseases often drool or dribble. Sometimes, a person who has a dental problem or an injury to the bones of the jaw will have trouble swallowing saliva.

Excessive saliva is usually a temporary problem and rarely a cause for concern but causes of increased saliva production include:

-Pregnancy
-New dentures
-Inflammation of membranes in the mouth
-A side effect of certain medications
-Or damage to the nerves that control the salivary glands

You should consult your doctor or dentist if you’re very concerned about it.

u have eaten like rice, or cabbage, or other veg tables and this normally happens. So the best thing known is a soup or Curry made from fresh ginger. Take some fresh ginger peel it if you want or just wash it carefully then finely chopped and make Aesop and put black peppers and onions and other spaces. Drink it like soup. Or have Gingery tea. Fresh Ginger will be better. Or put the ginger powder in your tea. Eat a sandwich with ginger and garlic chutney. Add some chilies greens to your food and this will cure. Do not eat boiled potatoes, cabbage, or boiled vegetables. If u do need just toast them with butter and add spices.
10 months ago

Are you eating anything with MSG or aspartame in it?

sometimes if you drink really strong coffee it causes it.

Almost any problem in the mouth, from dental decay to ulcers to tonsillitis can increase the amount of saliva produced. Another big stimulus to saliva production is our brains. We only have to think about or smell food to get the juices flowing. Other psychological factors that affect our brain, from anxiety to excitement, can alter the flow of saliva.

Excessive saliva, not necessarily a problem

However, increased saliva production is usually temporary and rarely causes difficulties. We make and swallow up to two liters of saliva every day, but barely notice its passing! Making more saliva doesn’t make much difference unless there are problems swallowing it.

If you can’t swallow saliva very easily, because of a sore throat or mechanical problems, such as in cerebral palsy or Parkinson’s disease (both relatively rare), you end up drooling. This is embarrassing, messy, and can make the skin around your lips and mouth sore because it contains the digestive enzyme amylase.

But I suspect that you have a different problem. You may simply have very powerful reflexes in your salivary ducts which squirt out a normal amount of saliva in a large jet from one of the several salivary glands around the inside of the mouth. The opening of one of these ducts may simply be pointing out of your mouth.

Occasionally a small stone may block or partially block one of the salivary ducts, which can cause a backlog of pressure and increased force behind the contractions to eject the saliva.

Drug treatment may have side effects

Some treatments, which include the drug atropine, can be used to reduce the flow of saliva. Although these may help in extreme drooling, they aren’t very effective and have undesirable side effects that may get in the way of the saliva’s important functions.

Saliva plays an important part in tasting food, digesting it, and cleaning the mouth afterward. It helps to lubricate the mouth for speech, keep the teeth strong and healthy, and is an important defense against bacteria and other infections. When the flow of saliva dries up, as it does in several conditions including some of the changes of aging, these normal functions can be severely disrupted.

Simpler solutions may be better. First get your dentist or doctor to check your mouth for any cause of excess saliva production, or a stone in the ducts. Then you may need to change your eating habits a little. Try not to talk and eat at the same time (just what our parents always taught us!) and try to talk without opening your mouth too wide or lifting your tongue (some of the largest salivary ducts open under the tongue).

Thanks for this article was last medically reviewed by Dr Trisha Macnair in July 2008

Sialorrhea-

thanks to

http://www.aafp.org/afp/2004/0601/p2628.html

NEIL G. HOCKSTEIN, M.D., University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

DANIEL S. SAMADI, M.D., Hackensack, New Jersey

KRISTIN GENDRON, M.D., University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

STEVEN D. HANDLER, M.D., University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Am Fam Physician. 2004 Jun 1;69(11):2628-2635.

Sialorrhea (drooling or excessive salivation) is a common problem in neurologically impaired children (i.e., those with mental retardation or cerebral palsy) and in adults who have Parkinson’s disease or have had a stroke. It is most commonly caused by poor oral and facial muscle control. Contributing factors may include hypersecretion of saliva, dental malocclusion, postural problems, and an inability to recognize salivary spill. Sialorrhea causes a range of physical and psychosocial complications, including perioral chapping, dehydration, odor, and social stigmatization, that can be devastating for patients and their families. Treatment of sialorrhea is best managed by a clinical team that includes primary health care providers, speech pathologists, occupational therapists, dentists, orthodontists, neurologists, and otolaryngologists. Treatment options range from conservative (i.e., observation, postural changes, biofeedback) to more aggressive measures such as medication, radiation, and surgical therapy. Anticholinergic medications, such as glycopyrrolate and scopolamine, are effective in reducing drooling, but their use may be limited by side effects. The injection of botulinum toxin type A into the parotid and submandibular glands is safe and effective in controlling drooling, but the effects fade in several months, and repeat injections are necessary. Surgical intervention, including salivary gland excision, salivary duct ligation, and duct rerouting, provides the most effective and permanent treatment of significant sialorrhea and can greatly improve the quality of life of patients and their families or caregivers.

Saliva is secreted by the six major salivary glands (two parotid, two submandibular, and two sublingual) and several hundred minor salivary glands. The major salivary glands produce 90 percent of the approximately 1.5 L of saliva that is secreted per day. In the unstimulated (basal) state, 70 percent of saliva is secreted by the submandibular and sublingual glands. When stimulated, salivary flow increases by five times, with the parotid glands providing the preponderance of the saliva.1

The various functions of saliva include mechanical cleansing of the mouth, contributing to oral homeostasis, and helping to regulate oral pH. Saliva also has bacteriostatic and bactericidal properties that contribute to dental health and decrease oral odor. It is important in the lubrication of food boluses, and the amylase in saliva begins the digestion of starches.

The parasympathetic nervous system innervates the parotid, submandibular, and sublingual glands with fibers that originate in the pons and medulla, and synapse in the otic and submandibular ganglia. Postganglionic fibers from the otic ganglion provide the secretory function to the parotid gland and fibers from the submandibular ganglion supply secretory function to the submandibular and sublingual glands. The flow of saliva is enhanced by sympathetic innervation, which promotes the contraction of muscle fibers around the salivary ducts.

Sialorrhea (drooling or excessive salivation) is defined as saliva beyond the margin of the lip. This condition is normal in infants but usually stops by 15 to 18 months of age. Sialorrhea after four years of age generally is considered to be pathologic.

Physical and psychosocial complications of sialorrhea range from mild and inconvenient symptoms to severe problems that can have a significant negative impact on the quality of life. Physical complications include perioral chapping and maceration with secondary infection, dehydration, and foul odor. The psychosocial complications include isolation, barriers to education (such as an inability to share books or computer keyboards), and increased dependency and level of care. Caretakers and loved ones may find it more difficult to demonstrate affection with affected patients, contributing to a potentially devastating stigmatization.

Etiology

Sialorrhea usually is caused by neuromuscular dysfunction, hypersecretion, sensory dysfunction, or anatomic (motor) dysfunction. The most common cause is neuromuscular dysfunction. In children, mental retardation and cerebral palsy are commonly implicated; in adults, Parkinson’s disease is the most common etiology. Pseudobulbar palsy, bulbar palsy, and stroke are less common causes (Table 1).

Hypersecretion commonly is caused by inflammation, such as teething, dental caries, and oral cavity infection. Other causes of hypersecretion include side effects from medications (i.e., tranquilizers, anticonvulsants), gastroesophageal reflux, toxin exposure (i.e., mercury vapor), and rabies.

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TABLE 1

Etiology of Sialorrhea

Neuromuscular/sensory dysfunction
	Mental retardation
	Cerebral palsy
	Parkinson’s disease
	Pseudobulbar*
	Bulbar palsy*
	Stroke*
Hypersecretion †
	Inflammation (teething, dental caries, oral-cavity infection, rabies)
	Medication side effects (tranquilizers, anticonvulsants)
	Gastroesophageal reflux
	Toxin exposure (mercury vapor)
Anatomic ‡
	Macroglossia (enlarged tongue)
	Oral incompetence
	Dental malocclusion
	Orthodontic problems
	Head and neck surgical defects (i.e., “Andy Gump” deformity)

*—Less common.

†—Usually controlled by increased swallowing.

‡—Frequently exacerbate existing problems.

Under normal circumstances, persons are able to compensate for increased salivation by swallowing. However, sensory dysfunction may decrease a person’s ability to recognize drooling, and anatomic or motor dysfunction may impede the ability to manage increased secretions.

Anatomic abnormalities are usually not the sole cause of drooling but commonly exacerbate other causative conditions. Macroglossia (enlarged tongue) and oral incompetence may predispose patients to salivary spill. Unfortunately, neither of these conditions is easily remedied. Malocclusion and other orthodontic problems may compound oral incompetence; orthodontic correction can reduce sialorrhea.

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FIGURE 1.

“Andy Gump” deformity. This anatomic defect results from resection of the anterior mandibular arch without adequate reconstruction.

Surgical defects following major head and neck resection and reconstruction also may cause sialorrhea. The most notable example of these anatomic defects is the “Andy Gump” deformity, which is caused by the loss of the anterior mandibular arch (Figure 1).

Assessment of Sialorrhea

Objective and subjective measures have been developed to quantify sialorrhea. The objective tests using radioisotope scanning and collection cups strapped to the patient’s chin are used primarily for research purposes. A variety of subjective scales for sialorrhea have been described.2 One system rates the severity of drooling on a five-point scale and the frequency of drooling on a four-point scale(Table 2).3 Although scales are useful in assessing and monitoring therapy, the impact of sialorrhea on the patient’s quality of life is the most important factor in determining the necessity of therapy.

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TABLE 2

System for Assessment of Frequency and Severity of Drooling

DROOLING		POINTS
Severity
	Dry (never drools)	1
	Mild (wet lips only)	2
	Moderate (wet lips and chin)	3
	Severe (clothing becomes damp)	4
	Profuse (clothing, hands, tray, objects become wet)	5
Frequency
	Never drools	1
	Occasionally drools	2
	Frequently drools	3
	Constantly drools	4

Information from Thomas-Stonell N, Greenberg J. Three treatment approaches and clinical factors in the reduction of drooling. Dysphagia 1988;3:75.

Management

Treatment of sialorrhea is best accomplished by using a team approach.4 The primary care physician usually focuses on the complete history and physical examination of the patient, with special attention to the impact of drooling on quality of life and the potential for improvement. Speech pathologists and occupational therapists work with patients to improve their swallowing mechanics and to support their posture with devices such as the head-back wheelchair. Dentists and orthodontists assess and treat dental and oral diseases and malocclusion. Otolaryngologists identify and correct causes of aerodigestive obstruction like macroglossia and adenotonsillar hypertrophy that contribute to drooling. Neurologists, otolaryngologists, and primary care physicians can assess the patient for significant cranial neuropathies.

After a thorough assessment, a consensus on appropriate treatment options should be developed by the treatment team, the patient, and the patient’s family. Treatments can be offered in a stepwise fashion, from least invasive, nonsurgical therapies to most invasive.

For minimal problems, in children under four years of age, or in adults with unstable neurologic function, observation is frequently the best option.4 Minimal problems also can be treated with a feeding program aimed at improving oromotor control, although this effort is rarely successful.

Any situational factors should be corrected, and dental malocclusion and caries should be treated. Adenotonsillectomy should be performed, when indicated, and patients should be fitted with appropriate wheelchairs and braces, if necessary.

Several orthodontic appliances may be used for the treatment of sialorrhea. Customized plates formed to fit the palate can aid in better lip closure.5,6 Movable beads can be placed on the upper plate; they stimulate tongue movement, thus helping to deflect saliva toward the pharynx. The use of these beads in combination with swallowing therapy has been successful in patients with moderate sialorrhea.7–9

Biofeedback and automatic cueing techniques have successfully treated patients with mild neurologic dysfunction and drooling. One study10 showed that biofeedback was successful in patients older than eight years who had mild to moderate problems. Patients are trained to associate a behavior with a cue; for example, swallowing or wiping the face is associated with an electronic beep. These devices can be used for several hours a day. The drawback to these devices is that patients become habituated to the stimulus, and the devices become less effective after repetitive use.11

Positive and negative reinforcement has been described as an adjunct in the management of sialorrhea in patients with moderate neurologic disease. Caretakers praise patients for not drooling or require them to wipe their faces when they forget to swallow.12

In a small, prospective study,13 acupuncture improved sialorrhea based on subjective measures in seven of 10 patients. Over a six-week period, patients were treated 30 times with needles placed in five locations in the tongue. Further study of the effectiveness of acupuncture in the treatment of sialorrhea is warranted.

If sialorrhea continues to interfere with the patient’s health and quality of life after non-invasive measures have been tried, medication, radiation, and surgical therapy should be considered.

ANTICHOLINERGIC MEDICATIONS

Anticholinergic medications block the parasympathetic innervation of the salivary glands. Several studies14–17 have demonstrated the effectiveness of glycopyrrolate and scopolamine (Transderm Scop) in the treatment of sialorrhea (Table 3).14–18 Unfortunately, even these relatively selective anticholinergic medications have side effect profiles that rise in proportion to their efficacy.

Glycopyrrolate is best known for its drying properties and limited central nervous system activity. Prospective, randomized trials14,15 of the use of this agent in the treatment of sialorrhea have demonstrated a significant reduction in drooling; however, approximately 20 percent of patients stopped taking the medicine because of side effects, and 23 percent experienced behavior changes.14,15 Transdermal scopolamine, applied as a patch behind the ear, was well tolerated in short-term studies,16,17 but its use was limited by side effects of urinary retention and blurred vision.

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TABLE 3

Medications for Treatment of Sialorrhea

AGENT	HOW SUPPLIED	DOSAGE	SIDE EFFECTS	COST*
Glycopyrrolate	Scored tablets,† 1 or 2 mg	Adults: Start at 0.5 mg orally, one to three times daily; titrate to effectiveness and tolerability‡	Constipation, excessive oral dryness, urinary retention, blurred vision, hyperactivity, irritability	$ 0.66 per 1-mg tablet
		Children: 0.04 mg per kg per dose orally, two to three times daily; titrate to effectiveness and tolerability
Scopolamine (Transderm Scop)	Patch, 1.5 mg	Apply patch every day	Pruritus at patch site, urinary retention, irritability, blurred vision, dizziness, glaucoma	20.99 per four 1.5-mg patches
Botulinum toxin A	Vial, 100 U per vial	Under ultrasound guidance, injections of 10 to 40 units into each submandibular and parotid gland	Pain at the injection site, excessive oral dryness	521.25 per vial

*—Estimated cost to the pharmacist based on average wholesale prices in Red Book. Montvale, N.J.: Medical Economics Data, 2001. The cost to the patient will be higher, depending on the prescription filling fee.

†—Tablets may be crushed if the patient prefers.

‡—The maximum daily dose for adults is 8 mg.

Information from references 14 through 18.

Anticholinergics are contraindicated in patients with glaucoma, obstructive uropathy, gastrointestinal motility disorders, and myasthenia gravis. Also, these medications often are poorly tolerated in elderly patients who have multiple comorbidities.

BOTULINUM TOXIN

Intraglandular injection of botulinum toxin type A recently has been reported to improve sialorrhea18 (Table 3).14–18 Under ultrasound guidance, botulinum toxin type A was injected into the bilateral parotid and submandibular glands of 10 adult patients. Nine of the patients improved, and no patient had complications. Treatment response lasted approximately five months, making repeat treatments necessary for long-term control.

GASTROESOPHAGEAL REFLUX CONTROL

Many developmentally delayed or neurologically impaired patients who have sialorrhea also have significant gastroesophageal reflux. It has been postulated that controlling reflux will reduce drooling; however, this conjecture has not been confirmed by research, and it is unlikely that control of reflux has any clinically significant effect on sialorrhea.19

RADIATION THERAPY

Radiation to the salivary glands is a reasonable treatment option in elderly patients who are not candidates for surgery and cannot tolerate medical therapy.20 Radiation produces xerostomia that may last months to years. The dose may be titrated to reach the desired effect, and treatment can be repeated as necessary. Malignancies induced by radiation therapy typically do not occur until 10 to 15 years after treatment and, therefore, are less of a concern in patients who are elderly and debilitated.20

SURGICAL OPTIONS

Surgical options in the treatment of sialorrhea include surgery on the salivary glands and ducts and surgery to denervate the glands (Table 4). Surgery to denervate the salivary glands is performed through the middle ear, where the tympanic plexus and chorda tympani travel before entering the major salivary glands. The procedure is relatively simple and fast and does not require general anesthesia. This surgery has few side effects, and patients typically do not complain of loss of taste. Unfortunately, the salivary function returns within six to 18 months, when nerve fibers regenerate.21

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TABLE 4

Advantages and Disadvantages of Surgical Therapies for Sialorrhea

SURGICAL THERAPY	ADVANTAGES	DISADVANTAGES
Submandibular duct relocation	No external scar	Duct relocation is an uncommon procedure
	Low incidence of ranula with sublingual gland excision	Duct relocation is an uncommon procedure
		Potential for anterior dental caries
		Without sublingual gland excision, the patient may develop ranula
		Potential for aspiration
Submandibular gland excision	Very good control of sialorrhea	External scar
Submandibular gland excision	Commonly performed procedure	Potential for dental caries
Parotid duct relocation	Redirects flow in the stimulated state	Risk of sialocele
		Potential for aspiration
		Relocation is an uncommon procedure
Parotid duct ligation	Simple, fast procedure	Risk of sialocele
Parotid duct ligation	Decreases flow in the stimulated state	Risk of sialocele
Transtympanic neurectomy	Technically easy, fast procedure	Predictable return of salivary function requires multiple procedures
	Does not require general anesthesia
	Useful in elderly patients

The most definitive treatment of sialorrhea is surgery to excise the major salivary glands or to ligate or reroute the major salivary ducts. This procedure typically involves a combination of parotid duct ligation or rerouting with either submandibular gland excision or duct rerouting. Sublingual gland excision is suggested if the submandibular ducts are rerouted to prevent the formation of salivary retention cysts.22,23 Preservation of salivation with reduction of drooling has been demonstrated following rerouting of the parotid and submandibular ducts to the posterior oropharynx, and rerouting procedures spare patients external scars and the risk of facial nerve injury.24–26

The most definitive surgical procedure, which includes bilateral parotid duct ligation and submandibular gland excision, is highly successful, with nearly total elimination of sialorrhea, a low incidence of facial weakness, and significant patient and caretaker satisfaction.27 Although this is the most invasive of treatment options, the severity of sialorrhea may be sufficient to require such aggressive therapy.

The Authors

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NEIL G. HOCKSTEIN, M.D., is a fourth-year resident in the Department of Otolaryngology-Head and Neck Surgery at the University of Pennsylvania School of Medicine, Philadelphia. He received his medical degree from Jefferson Medical College of Thomas Jefferson University, also in Philadelphia.…

Figure 1 provided by Dr. Neil G. Hockstein.

REFERENCES

show all references

1. Stuchell RN, Mandel ID. Salivary gland dysfunction and swallowing disorders. Otolaryngol Clin North Am. 1988;21:649–61.…

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