Drooling

Problems with Drooling in Parkinson’s Disease

Is drooling a common problem in Parkinson’s Disease?

Drooling or dribbling is a common problem experienced by people with Parkinson’s Disease. The textbooks refer to this as sialorrhoea.

What causes the drooling?

Drooling occurs because the natural tendency to swallow every now and again (even when not eating) is slowed down. It is not caused by an increase in saliva. The reduction in swallowing combined with a reduced awareness, stooped, poor posture and an inadequate lip seal affects the control of the saliva in and from the mouth. As a result, saliva tends to accumulate in the mouth and, rather than being swallowed, it can overflow.

Many people have poor lip closure due to their Parkinson’s and a flow of saliva from the mouth will occur if the lips do not seal tightly. There is also a tendency for the head to be bent forwards so that the chin points downwards. This will make the drooling worse.

Apart from interfering with speech, and being embarrassing for the person with Parkinson’s, overflowing of saliva can cause a soreness and rawness of the skin on the chin; clothes can become stained and many people have stale breath because of their drooling difficulties. When a person with Parkinson’s experiences extreme problems with excessive salivation, specialist help is usually required.

 

What can a person with Parkinson’s do to improve drooling by themselves or with specialist help?

In some cases, simply improving posture can alleviate the problem. A physiotherapist can advise on problems of posture. See the Parkinson’s Association’s Information Sheet on Physiotherapy and Parkinson’s Disease.

Referral to a Speech and Language Therapist for assessment and advice is important to identify the problems of poor posture, lip seal, tongue control and awareness, as well as any difficulties with swallowing that may be contributing to the problem of drooling. A GP or consultant can provide a referral to a Speech and Language Therapist  working within the HSE or directly to private SLTs. Self-referral to see a Speech and Language Therapist privately is also possible.

The Speech and Language Therapist can advise on techniques to improve lip closure and techniques and exercises to facilitate a more functional swallow. People who experience poor lip closure may be able to close their lips with their fingers or support their head up by cupping their chin in their hand. This can be tiring and is not very practical. There are devices which can be used to retrain lip seal and these are very effective. A Speech and Language Therapist can advise further.

A person with Parkinson’s can also try these simple exercises at home in front of the mirror:

Close the lips as tightly as possible and hold for a count of four, relax, then repeat five times;

Smack the lips together as if puffing on a pipe;

Stretch the lips in a wide smile, hold for a count of four and relax;

Purse the lips as if you are going to whistle  or kiss someone, hold for a count of four and relax.

It is also important to remember to swallow to reduce the amount of saliva in the mouth. Set reminders to swallow at set intervals.

An Occupational Therapist can advise on seating that may help. Referral to an Occupational Therapist working in the HSE is usually via a GP, Consultant, Parkinson’s Disease Nurse Specialist (PDNS) or Public Health Nurse. Self-referral to a private Occupational Therapist is also possible. Details of Occupational Therapists with private practices can be obtained from the Association of Occupational Therapists in Ireland.

There are drugs that can help reduce the production of saliva. e.g. atropine, hyoscine and propantheline. Although these drugs are licensed for other indications, it is possible to make use of their anti cholinergic activity, which includes the drying of saliva. Anti cholinergics must be prescribed by a doctor who can ensure that they are suitable; especially since people with Parkinson’s often take several drugs and may be having treatment for other conditions as well.

Anti cholinergics have side effects which may be more problematic in older people. These include blurred vision and urinary retention. Occasionally, they bring on drowsiness, hallucinations, excitement and behavioural problems. It is unwise to use over- the-counter cough or cold preparations without seeking the advice of a doctor.

Injections of botulinum toxin into the salivary glands can also be helpful. Botulinum toxin is a powerful nerve toxin which is sometimes used to treat dystonia in Parkinson’s and is now being used to treat excessive salivation in some people. It interrupts the nerves messages to the glands that tell them to secrete. Relief from excessive salivation can, in some cases, last up to three months. However, like all drugs, botulinum toxin has side effects and will not be suitable for everyone.

Anyone experiencing severe difficulties with excessive salivation which has proven to be resistant to speech and language therapy intervention should ask their GP to refer them to a Parkinson’s specialist, either a neurologist or a physician with expertise in the care of older people. Any preparation that is prescribed will then be monitored by these experts.

Occasionally specialists may refer to a radiography department where radiation treatment may be given that can limit the effectiveness of the glands that secrete saliva.

Others may refer to an oral surgeon to explore the possibility of an operation to remove the salivary glands. It is important for a person with Parkinson’s to discuss these options with their doctor. Any operation can have risks and they should be aware of all that is involved. As a result surgery is not widely recommended.

Other useful information

If it is decided to seek assistance from any of the specialist therapists listed in this Information Sheet privately, the person with Parkinson’s will have to  pay for this private treatment. However there  may  be some reimbursement for such therapies under private health insurance schemes. Check individual policies for specific reimbursement entitlements. Tax relief may be obtained on specialist therapy fees (see current revenue guidelines for applicable threshold and rates).

Acknowledgements:

Parkinson’s Association of Ireland would like to thank Parkinson’s UK for permission to use PDS Leaflet FS22 and PDS Leaflet FS07 as the basis for this Information Sheet.

Also, our thanks to Aisling Keogh, Speech and Language Therapist, Speech Matters SLT Clinic for endorsing this leaflet.

Other Relevant Information Sheets:

EX2: Physiotherapy and Parkinson’s Disease

NM2.1: Speech and Language Therapy in Parkinson’s Disease

NM2.2: Problems with Swallowing in Parkinson’s Disease

Further Information:

Irish Association of Speech and Language Therapists (IASLT)

P.O. Box 541, Ballinlough, Co. Cork Telephone: +353 (0)85 7068707

E-mail: info@iaslt.ie • Website: www.iaslt.ie

Irish Association of Speech and Language Therapists in Private Practice (IASLTPP)

PO Box 11074, Dublin 9.

Telephone: 01 8787959 Website: www.iasltpp.com

Association of Occupational Therapists of Ireland

PO Box 11555, Ground Floor Office, Bow Bridge House, Bow Lane, Kilmainham, Dublin 8 Telephone: 01 6337222

Website: www.aoti.ie • Email – aoti@eircom.net

Irish Society of Chartered Physiotherapists (ISCP).

Royal College of Surgeons, 123, St. Stephen’s Green, Dublin 2. Telephone: +353 1 402 2148 • Fax: +353 1 402 2160

E-mail: info@iscp.ie