What is the treatment for excessive salivation (hypersalivation)?

From the Guidelines

The treatment for excessive salivation (hypersalivation) should start with a therapeutic trial of an anticholinergic medication as first-line therapy, with continued use only if benefits are perceived to outweigh potential side effects. This approach is based on the most recent and highest quality study available, which suggests that anticholinergic medications can be effective in reducing saliva production, although the certainty of evidence is very low 1.

First-Line Treatment Options

• Anticholinergic medications such as glycopyrrolate, scopolamine patches, or atropine drops can be used to block acetylcholine receptors and reduce saliva production.
• The choice of medication and dosage should be individualized, considering factors such as the patient's underlying condition, potential side effects, and response to treatment.
• Starting with lower doses and titrating up is recommended to minimize side effects, which may include dry mouth, blurred vision, and constipation.

Alternative Treatment Options

• Botulinum toxin injections into the salivary glands can provide relief for 3-6 months by blocking nerve signals that stimulate saliva production, and can be considered for patients who have an inadequate response or are intolerant of anticholinergic therapy 1.
• Non-pharmacological approaches, such as speech therapy to improve swallowing, oral motor exercises, and behavioral modifications, can also be beneficial in managing excessive salivation.
• Treating underlying conditions like GERD, oral infections, or adjusting medications that cause hypersalivation is essential to address the root cause of the problem.

Important Considerations

• Prior to considering pharmacological treatment, a clinical swallow exam or instrumental swallow evaluation should be carried out to assess the patient's swallowing function and risk of aspiration 1.
• Patients should maintain good oral hygiene to prevent complications from excessive saliva.
• The treatment plan should be tailored to the individual patient's needs and response to treatment, with regular monitoring and adjustments as necessary.

From the FDA Drug Label

GLYCOPYRROLATE ORAL SOLUTION 1MG/5ML is an anticholinergic indicated to reduce chronic severe drooling in patients aged 3-16 years with neurologic conditions associated with problem drooling (e.g., cerebral palsy). Glycopyrrolate is a competitive inhibitor of acetylcholine receptors that are located on certain peripheral tissues, including salivary glands. Glycopyrrolate indirectly reduces the rate of salivation by preventing the stimulation of these receptors.

The treatment for excessive salivation (hypersalivation) is glycopyrrolate oral solution, which is indicated to reduce chronic severe drooling in patients aged 3-16 years with neurologic conditions associated with problem drooling.

• The initial dose is 0.02 mg/kg three times daily and can be titrated in increments of 0.02 mg/kg every 5-7 days based on therapeutic response and adverse reactions.
• The maximum recommended dose is 0.1 mg/kg three times daily, not to exceed 1.5-3 mg per dose based upon weight.
• Glycopyrrolate oral solution should be dosed at least one hour before or two hours after meals 2.

From the Research

Treatment Options for Excessive Salivation

The treatment of excessive salivation, also known as hypersalivation or sialorrhea, can be managed through various approaches. These include:

• Conservative measures such as observation, postural changes, and biofeedback 3
• Medications like anticholinergic drugs (e.g., glycopyrrolate and scopolamine) to reduce saliva production 3, 4, 5
• Botulinum toxin type A injections into the parotid and submandibular glands to control drooling 3, 6, 4
• Surgical interventions, including salivary gland excision, salivary duct ligation, and duct rerouting, for more severe cases 3
• Radiotherapy for certain conditions, such as neurodegenerative diseases 4

Management of Medication-Induced Excessive Salivation

In cases where excessive salivation is caused by medication, treatment options may include:

• Discontinuing or adjusting the offending medication
• Using anticholinergic medications (e.g., atropine-related oral anticholinergics) to reduce cholinergic tone 6
• Increasing adrenergic tone with medications like clonidine patch 6
• Botulinum injections into the parotid gland for refractory cases 6

Diagnostic Evaluations

Diagnostic evaluations for excessive salivation may involve:

• Transnasal swallowing endoscopy to assess dysphagia 4
• Radiologic assessments to complete the diagnostic workup 4
• Sialendoscopy, a gland-sparing technique, to treat obstructive and nonobstructive disorders 7

Treatment Considerations

Treatment considerations for excessive salivation include:

• A multidisciplinary approach involving primary health care providers, speech pathologists, occupational therapists, dentists, orthodontists, neurologists, and otolaryngologists 3
• Close follow-up and monitoring to establish compliance and adjust therapies as needed 4
• Individualized treatment plans to optimize treatment effects and minimize side effects 4