Sialorrhea
Information on the causes, symptoms, and the most effective treatments for hypersalivation.
Symptoms and Causes
Sialorrhea or ptyalism, also known as hypersalivation, is a condition characterized by an excess amount of saliva remaining in the mouth. Although it is usually due to impaired ability to swallow saliva, it may also result from overproduction.
Considering saliva behavior in the oral cavity, two types of sialorrhea exist:
- Anterior sialorrhea: saliva spills over the lip commissures and exits the mouth.
- Posterior sialorrhea: saliva accumulates in the throat. Although less noticeable, it has more severe consequences, as it may lead to choking, pneumonia, or breathing difficulties.
Although ptyalism is normal during the first two years of life, it is considered pathological from the age of four. Sialorrhea significantly worsens patients’ quality of life, and its prognosis varies depending on its underlying cause.
Symptoms
The most prominent symptom of sialorrhea is an excess of saliva in the mouth, which may spill over and moisten the lips and chin. It is also characterized by:
- Lip desquamation.
- Halitosis.
- Fatigue of the jaw muscles.
- Dermatitis around the mouth.
- Altered sense of taste.
- In posterior sialorrhea, cough and nausea.
Causes
Sialorrhea has two main causes:
- Excessive saliva production by the salivary glands.
- Drug-induced sialorrhea: certain medications can cause this type of ptyalism, such as antiepileptics, anticonvulsants, muscle relaxants, antihistamines, or antipsychotics.
- Irritation-induced sialorrhea: certain oral conditions, such as ulcers or dental caries, or the placement of orthodontic appliances or dentures, may promote increased saliva production.
- Inability to swallow saliva, which is produced in normal amounts. In this category, the causes may vary widely:
- Anatomical sialorrhea: due to anatomical alterations of the mouth or pharynx, such as dental malocclusion, airway obstruction, or mouth breathing.
- Functional or neuromuscular sialorrhea: caused by impaired orofacial muscle function that hinders swallowing. It may also result from a sensory alteration preventing the detection of excess saliva.
- Neurological or systemic sialorrhea: neurological diseases disrupt the swallowing reflex. Common causes include Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis, facial paralysis, or brain injury.
Risk Factors
The risk of developing sialorrhea increases in the following situations:
- Use of medications that increase saliva production.
- Use of removable dental appliances or prostheses.
- Hormonal changes, especially during pregnancy.
- Presence of gastrointestinal disease, primarily gastroesophageal reflux.
- Neurological or brain disorders.
Complications
The most common complications of sialorrhea include:
- Dermatitis: irritation of the skin on the lips and chin.
- Oral and dental infections.
- Difficulty swallowing, breathing, or speaking.
- Aspiration pneumonia, in posterior sialorrhea.
- Low self-esteem.
- Social isolation.
Prevention
Sialorrhea cannot always be prevented, although habit changes may reduce symptoms:
- Maintain good oral and dental hygiene.
- Attend dental check-ups to detect caries early.
- Avoid consuming irritating foods (acidic, spicy, or highly sugary).
- When possible, replace medications that increase saliva production.
Which specialist treats sialorrhea?
Sialorrhea is diagnosed in a family and community medicine and, depending on the cause, is treated by specialists in dentistry, otorhinolaryngology, or neurology.
Diagnosis
The following tests are conducted to diagnose sialorrhea:
- Otolaryngological examination:
- Visual inspection of the oral cavity to detect possible swallowing difficulties, dental malocclusion, postural problems, upper airway obstruction, or mouth breathing.
- Palpation of the salivary glands to identify inflammation or cysts.
- Visual analog scale (VAS): a technique used to assess the intensity of a symptom and the discomfort it causes. In this case, discomfort from excess saliva is scored from 0 to 10.
- Teacher Scale: a scoring system used to classify sialorrhea according to its severity:
- Dry sialorrhea: no excess saliva (1 point).
- Mild sialorrhea: saliva moistens the lips (2 points).
- Moderate sialorrhea: both the lips and chin are moistened (3 points).
- Severe sialorrhea: saliva reaches the clothing (4 points).
- Profuse sialorrhea: excess saliva moistens the lips, chin, clothing, hands, and nearby objects (5 points).
- Drooling impact scale: a procedure used to measure the amount of saliva that drips outside the mouth.
Treatment
Sialorrhea requires a multidisciplinary approach that considers multiple factors. The most effective techniques include:
- Speech therapy: exercises to promote lip closure, suction, and swallowing, aiming for these actions to become automatic.
- Medications: certain drugs, such as scopolamine or atropine, help reduce saliva secretion by blocking muscarinic receptors in the salivary glands.
- Botulinum toxin: injected into the salivary glands to block saliva production. Its effects last approximately three months.
- Surgical intervention: considered a last resort when patients do not respond adequately to previous approaches. Depending on each case, treatment may involve salivary duct ligation, submandibular gland excision, diversion of salivary excretory ducts, tonsil reduction, or adenoidectomy.
