Treatment of Excessive Saliva Production (Sialorrhea)
The treatment of excessive saliva production should follow a stepped approach starting with anticholinergic medications as first-line therapy, followed by botulinum toxin injections for refractory cases, and salivary gland radiation therapy as a last resort for severe cases unresponsive to other treatments. 1
Evaluation Before Treatment
Before initiating treatment for sialorrhea, it's essential to:
- Measure baseline salivary gland function through whole salivary flow measurement
- Rule out conditions that mimic sialorrhea (candidiasis, burning mouth syndrome)
- Consider salivary scintigraphy for further evaluation if needed 1, 2
Treatment Algorithm Based on Severity
First-Line Approaches
Anticholinergic Medications:
- Oral anticholinergics (glycopyrrolate) are the initial treatment of choice 1, 2
- Glycopyrrolate dosing:
- For adults: Start with low dose and titrate based on response
- For children 3-16 years: Start at 0.02 mg/kg three times daily, titrate up to maximum 0.1 mg/kg three times daily (not exceeding 1.5-3 mg per dose) 3
- Administer at least one hour before or two hours after meals 3
- Monitor for side effects: dry mouth, constipation, urinary retention, blurred vision, flushing
Non-pharmacological Approaches (for mild cases or as adjuncts):
Second-Line Approaches
Botulinum Toxin Injections:
- Indicated when anticholinergics are ineffective or poorly tolerated
- Injected into salivary glands (parotid and submandibular)
- Effects last 3-4 months, requiring repeated injections
- Side effects include pain at injection site and temporary thickening of saliva 1, 5
Third-Line Approaches
Salivary Gland Radiation Therapy:
- Reserved for severe, refractory cases
- Provides long-lasting relief but causes irreversible dryness
- Should only be performed at experienced centers
- Risk-benefit ratio must be carefully considered 1, 6
Special Considerations by Underlying Cause
Neurological Disorders (Parkinson's, ALS, Cerebral Palsy)
- Sialorrhea is often due to impaired swallowing rather than hypersecretion
- Focus on improving swallowing function alongside saliva reduction
- Consider more aggressive treatment due to aspiration risk 1, 5
Medication-Induced Sialorrhea
- Common with clozapine, risperidone, and other psychotropics
- Consider dose adjustment or splitting daily dose of causative medication
- Add anticholinergics if dose adjustment isn't possible 4
Sjögren's Syndrome and Paradoxical Sialorrhea
- In Sjögren's, patients may experience both xerostomia and periods of excessive salivation
- Treatment should be tailored to the predominant symptom 1
Monitoring and Follow-up
- Assess treatment response after 1-2 weeks of anticholinergic therapy
- Monitor for constipation within 4-5 days of starting anticholinergics or after dose increases 3
- Regular dental check-ups to prevent complications from altered salivary flow
- Adjust treatment based on efficacy and side effects 2
Complications to Watch For
- Constipation or intestinal pseudo-obstruction with anticholinergics
- Risk of heat prostration in high ambient temperatures with anticholinergics
- Aspiration pneumonia if sialorrhea persists, especially in neurologically impaired patients
- Social stigmatization and skin breakdown around the mouth 5, 7
Treatment Pitfalls to Avoid
- Failing to distinguish between true hypersalivation and poor oral clearance
- Not considering drug interactions with anticholinergics
- Using anticholinergics in patients with glaucoma, urinary retention, or severe constipation
- Delaying treatment in patients at risk for aspiration 6
The management of sialorrhea requires a systematic approach with careful consideration of the underlying cause, severity of symptoms, and patient-specific factors. While anticholinergics remain the cornerstone of treatment, botulinum toxin and radiation therapy provide effective options for refractory cases.