Drooling
Synonyms and keywords: ptyalism; sialorrhea; hypersalivation; Polysialia; Salivation excessive; Salivary hypersecretion; Sialism

# Overview
Drooling is the uncontrollable flow of saliva outside the mouth. It can occur in either some nervous system disorders or anatomic abnormalities of the oral cavity. Either the production of saliva is excessive, the musculature of the mouth which normally controls the oral opening, is weak and not functioning to the adequate strength to help keep the saliva inside or there is difficulty in swallowing.
Firstly we will discuss the production of saliva, which is carried out by the salivary glands. Upon receiving the excitatory stimulus from salivary nuclei present in the brain stem, saliva is produced, which occurs in response to the taste, and visual stimuli received from the tongue and other parts of the mouth. These are categorized into minor and major salivary glands. The major glands, which are most impressive are present in the base of the mouth, front of teeth, and in the cheeks, known as submandibular, parotid, and sublingual glands. So in total, there are 6 major glands that secrete saliva.
Isolated drooling is a common phenomenon in babies, often associated with teething, but it usually stops at around 15-36 months, when the baby develops salivary continence. Drooling in infants and young children may be exacerbated by upper respiratory infections and nasal allergies. The persistence of Sialorrhea after 4 years of age is therefore considered pathologic at times. It may persist due to hyper-salivation, or neurologic disorders like cerebral palsy, Parkinsons disease, and amyotrophic lateral sclerosis, or as a side effect of medications. The most common cause of sialorrhea in children is Cerebral palsy whereas, in adults, Parkinson's disease is the most common cause. Other contributing factors for drooling are dental malocclusion, postural issues, and an inability to recognize salivary spills.
Drooling associated with fever or trouble swallowing may be a sign of a more serious disease including:
- Retropharyngeal abscess
- Peritonsillar abscess
- Tonsilitis
- Mononucleosis
- Strep throat
- Parkinson's disease
Sudden onset drooling may be an indication of poisoning (predominantly by pesticides) or a reaction to snake or insect venom. It can also be a side effect of numbed mouth from either orajel use in the dentist's office or medications. Some neurological problems also cause drooling. Excess intake of Capsaicin can lead to drooling as well, an example being the ingestion of particularly high Scoville Unit chili peppers.
Seasonal Allergies from pollen, trees, grass, mold, and weeds can also cause excessive saliva production and be a cause for drooling. Another form of ptyalism is associated with pregnancy, most common in women with a condition known as Hyperemesis Gravidarium, or uncontrollable and frequent nausea and vomiting during pregnancy which is far worse than typical "morning sickness". With Hyperemesis, ptyalism is a side-effect, which is a natural response to uncontrollable vomiting. With normal vomiting, salivary glands are stimulated to lubricate the esophagus and mouth to aid in expelling stomach contents. During a hyperemesis pregnancy, many women complain of excessive saliva and an inability to swallow this saliva. Some women note-having to carry around a "spitoon" or using a cup to spit. Swallowing their own saliva has been noted to gag and further nauseate the women making the hyperemesis that much worse.
There are several theories as to the causes of hyperemesis and related symptoms such as ptyalism. Many physicians are reluctant to treat hyperemesis since they don't see it as a true physiological illness but rather "in the patient's mind" . Many pregnant women who suffer end up terminating the pregnancy. Others refuse to carry another child. The most frequent act is preparing for the onset of hyperemesis if a subsequent pregnancy is expected.
Drooling is very bothersome, and can lead to many complications, both physical and psychosocial. Maceration and infection of the skin around the mouth, halitosis, dehydration, abnormalities in speech, and feeding difficulties are some of the complications. Also, drooling increases the chances of aspiration of saliva, food, or fluids into the lungs, especially with deranged reflex mechanisms like gagging or coughing. Moreover, people suffering from this face psychosocial troubles like isolation, education difficulties,  increased level of dependency, decreased self-esteem, and difficult socialization. This overall, sialorrhea has a significant negative impact on the quality of life.

# Physiology
The major salivary glands in our oral cavity are the parotid, submandibular, and sublingual glands; amongst which the parotid glands are the largest. Saliva produced by these glands help in lubrication, and digestion of food, providing immunity, and maintaining of homeostasis in the human body. The salivary secretion is controlled mainly by the parasympathetic nervous system, with a minor contribution of sympathetic nervous system. The parasympathetic fibers originating from the pons and medulla, synapse in the otic and submandibular ganglia. The postganglionic fibers which originate from otic and submandibular ganglion regulate functions of parotid gland and submandibular/sublingual glands respectively. The sympathetic signals aid in contraction of muscle fibers surrounding the ducts of these glands, which result in the flow of saliva.
About 1.5 L of saliva is produced every day, 90% of which is carried out by the major salivary glands provide. Without stimulation, in the basal state, 70% of total saliva is produced by the submandibular and sublingual glands. Upon stimulation, the salivary secretion increases by five times. Chewing is an important source which causes stimulation of salivary glands. Salivary glands produce 2 types of saliva; thin and watery serous saliva, produced mainly by parotid glands and viscous thick saliva, produced predominantly by sublingual and submandibular glands. Excessive production of both can be a problema. Serous watery saliva consistently keeps on spilling from the side of the mouth, and viscous saliva being sticky, is harder to clear and often causes choking, which leads to panic.

# Causes

## Common Causes
- Retropharyngeal abscess
- Peritonsillar abscess
- Tonsilitis
- Mononucleosis
- Strep throat
- Parkinson's disease
- Epiglottitis
- Enlarged adenoids
- Dentures that are new or don't fit well
- Bell's palsy
- Cerebral Palsy

## Causes by Organ System

## Causes in Alphabetical Order
- Achillea  ptarmica
- Actinomycosis
- Acute Gastritis or Gastric  Ulcer
- Acute sinusitis
- All signs and symptoms
- Allergies
- Alveolar abscess
- Amaryllis poisoning
- Amyotrophic lateral  sclerosis
- Angelman-Like Syndrome
- Ankylosis of the  Temporomandibular Joint
- Antimony
- Aphthous Ulcers
- Arsenic poisoning
- Athetoid Cerebral Palsy
- Autism
- Balsam apple poisoning
- Bell's palsy
- Bilateral Facial Nerve  Palsy
- Bone Lesions
- Boston Ivy poisoning
- Botulism
- Bromide
- Bulbar Paralysis
- Bush lily poisoning
- Buttercup poisoning
- Cantharides
- carbidopa-levodopa
- Cerebral Palsy
- Cerebrovascular Accident
- Chancre
- Chronic sinusitis
- clonazepam (Klonopin)
- Clozapine (Clozaril
- Copper
- Dementia
- Dental Caries
- Dental implant
- Dental malocclusion
- Dentures that are new or  don't fit well
- Diphtheria
- Dog odor
- Donepezil
- Down syndrome
- Endoscopic foreign body  retrieval
- Enlarged adenoids
- Epiglottitis
- Epilepsy and Ataxia  Syndrome
- Epulis
- Esophageal atresia
- Esophageal food bolus  obstruction
- Excessive starch intake
- Familial dysautonomia
- Foix-Chavany-Marie  syndrome
- Foot-and-mouth disease
- Fragile X syndrome
- Galantamine
- Gastric distention or  irritation
- Gastroesophageal Reflux
- Guillain-Barre syndrome
- Heartburn or GERD  (reflux)
- Hyperemesis Gravidarum
- Hypoglossal Nerve palsy
- Hypotonia
- Infection in your mouth or  throat
- Iodide
- Jaw Fracture or  dislocation
- Jessamine poisoning
- Jonquil poisoning
- Juvenile Primary Lateral  Sclerosis
- Liver disease
- Loratadine
- Macroglossia
- Marsh marigold poisoning
- Mayapple poisoning
- Mental retardation
- Mercury poisoning
- Mexican tea poisoning
- Microcephaly
- Mixed Cerebral Palsy
- Mobius syndrome
- Mononucleosis
- Motion sickness
- Mountain Laurel poisoning
- Multiple sclerosis
- Mumps
- Myasthenia Gravis
- Nicotine nasal spray
- Nicotine poisoning
- Oral chemical burns
- Oral infectious Lesions
- Oral suppurative lesions
- Organophosphate insecticide  poisoning
- Pallidotomy
- Pancreatitis
- Parkinson disease
- Peritonsillar abscess
- Pilocarpine
- Poisoning  (pesticides)
- Potassium Chlorate
- Pregnancy
- Procyclidine
- Pseudobulbar paralysis
- Pyridostigmine
- Rabies
- Radiation Therapy
- Rattlesnake bite
- Reaction to snake or insect  venom
- Retropharyngeal Abscess
- Right parietal lobe  syndrome related Alzheimer's disease
- Rolandic Epilepsy
- Sarcoma of the jaw
- Sarin
- Schwartz-Jampel Syndrome
- Sea urchin poisoning
- Segawa syndrome, autosomal  recessive
- Sialorrhea
- Sinus infections
- Skunk cabbage poisoning
- Small Pox
- Smith-Magenis Syndrome
- Spastic paraplegia
- Split-leaf philodendron  poisoning
- Stomatitis
- Strep throat
- Stroke
- Swollen adenoids
- Syphilis
- Tonic seizure
- Tonic-Clonic seizure
- Tonsillitis
- Tuberculosis
- Voriconazole
- X-linked Ataxia  Telangiectasia
Achillea ptarmica
Alveolar abscess
Amaryllis poisoning
Amyotrophic lateral  sclerosis
Angelman-Like Syndrome,
Ankylosis of the  Temporomandibular Joint
Antimony
Aphthous Ulcers
Arsenic poisoning
Athetoid Cerebral Palsy
Autism
Balsam apple poisoning
Bell's palsy
Bilateral Facial Nerve  Palsy
Bone Lesions
Boston Ivy poisoning
Botulism
Bromide
Bulbar Paralysis
Bush lily poisoning
Buttercup poisoning
Cantharides
carbidopa-levodopa
Cerebral Palsy
Cerebrovascular Accident
Chancre
Chronic sinusitis
clonazepam (Klonopin),
Clozapine (Clozaril)
Copper
Dementia
Dental Caries
Dental implant
Dental malocclusion
Dentures that are new or  don't fit well
Diphtheria
Dog odor
Donepezil (patient  information)
Down syndrome
Endoscopic foreign body  retrieval
Enlarged adenoids
Epiglottitis
Epilepsy and Ataxia Syndrome
Epulis
Esophageal atresia
Esophageal food bolus  obstruction
Excessive starch intake
Familial dysautonomia
Foix-Chavany-Marie  syndrome
Foot-and-mouth disease
Fragile X syndrome
Galantamine
Gastric distention or  irritation
Gastroesophageal Reflux
Guillain-BarrA syndrome
Heartburn or GERD (reflux)
Hyperemesis Gravidarum
Hypoglossal Nerve palsy
Hypotonia
Infection in your mouth or  throat
Iodide
Jaw Fracture or  dislocation
Jessamine poisoning
Jonquil poisoning
Juvenile Primary Lateral  Sclerosis
Liver disease
Loratadine
Macroglossia
Marsh marigold poisoning
Mayapple poisoning
Mental retardation
Mercury poisoning
Mexican tea poisoning
Microcephaly
Mixed Cerebral Palsy
Mobius syndrome
Mononucleosis
Motion sickness
Mountain Laurel poisoning
Multiple sclerosis
Mumps
Myasthenia Gravis
Nicotine nasal spray
Nicotine poisoning
Oral chemical burns
Oral infectious Lesions
Oral suppurative lesions
Organophosphate insecticide  poisoning
Pallidotomy
Pancreatitis
Parkinson disease
Peritonsillar abscess
Pilocarpine
Poisoning  (pesticides)
Potassium Chlorate
Pregnancy
Procyclidine
Pseudobulbar paralysis
Pyridostigmine
Rabies
Radiation Therapy
Rattlesnake bite
Reaction to snake or insect  venom
Retropharyngeal Abscess
Right parietal lobe syndrome  related Alzheimer's disease
Rolandic Epilepsy
Sarcoma of the jaw
Sarin
Schwartz-Jampel Syndrome
Sea urchin poisoning
Segawa syndrome, autosomal  recessive
Sialorrhea
Sinus infections
Skunk cabbage poisoning
Small Pox
Smith-Magenis Syndrome
Spastic paraplegia
Split-leaf philodendron  poisoning
Stomatitis
Strep throat
Stroke
Swollen adenoids
Syphilis
Tonic seizure
Tonic-Clonic seizure
Tonsillitis
Tuberculosis
Voriconazole
X-linked Ataxia  Telangiectasia
Aconite

# Management
Sialorrhea is best managed by a team of primary health care providers, speech therapists, occupational therapists, dentists, orthodontists, neurologists, orthodontists, and otolaryngologists. Treatment options available for drooling can be either conservative, including just observation, some postural modifications, or biofeedback to more aggressive options like medication, radiation, or even surgical therapy. Anticholinergic medications, like glycopyrrolate or scopolamine, effectively reduce drooling, with certain side effects. The injection of botulinum toxin type A into the parotid and submandibular glands is another safe yet effective method of controlling drooling, but the effects fade in some months and we need to do repeat injections. Surgical interventions, like salivary gland excision, or duct ligation, and rerouting, are the most effective and permanent treatment options which greatly improve the quality of life of patients.

# Home care
Care for drooling due to teething includes good oral hygiene. Ice pops or other cold objects (e.g., frozen bagels) may be helpful. Care must be taken to avoid choking when a child uses any of these objects.
Drooling also is common in children with neurological disorders and those with undiagnosed developmental delay.

## The reason for excessive drooling seems to be related to;
- lack of awareness of the build-up of saliva in the mouth,
- infrequent swallowing,
- inefficient swallowing.

## Treatment of excessive drooling is related to these causes;
- increased awareness of the mouth and its functions,
- increased frequency of swallowing,
- increased swallowing skill.

# Sialorrhea
Sialorrhea is a condition characterized by the secretion of drool in the resting state. It is often the result of open-mouth posture from CNS depressants or sleeping on one's side. In the resting state, saliva may not build at the back of the throat, triggering the normal swallow reflex, thus allowing for the condition.

# Treatment
A comprehensive treatment plan incorporates several stages of care: correction of reversible causes, behavior modification, medical treatment, and surgical procedures.  Atropine sulfate tablets are indicated to reduce salivation and may be prescribed by doctors in conjunction with behaviour modification strategies.  In general, surgical procedures are considered after evaluation of non-invasive treatment options.