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Drooling

Drooling, medically termed sialorrhea or ptyalism, is the unintentional and excessive flow of saliva from the mouth beyond the lip margins, often resulting from impaired oral motor control, swallowing difficulties, or overproduction of saliva.^[1]^[2] This condition is physiologically normal in infants and young children, particularly peaking between 3 and 6 months of age during teething when saliva production increases to aid in tooth eruption, and it typically resolves by age 2 as neuromuscular coordination improves.^[1]^[3] In older children and adults, drooling is frequently pathological and linked to underlying conditions rather than true hypersalivation, with saliva production remaining within normal limits (approximately 0.5–1.5 liters per day from the parotid, submandibular, and sublingual glands under autonomic nervous system regulation).^[2] Common causes include neurological disorders such as cerebral palsy (affecting 10–38% of patients, primarily due to poor swallowing coordination) and Parkinson's disease (impacting 70–80% of individuals through reduced muscle tone and frequent swallowing).^[2] Other contributors encompass developmental issues like Down syndrome or autism, infections, allergies, gastroesophageal reflux disease (GERD), medications, and structural problems such as swollen adenoids or poor dentition.^[3]^[1] Drooling poses notable health and social challenges, including risks of aspiration (where saliva enters the lungs, potentially causing pneumonia), skin maceration around the mouth and chin, dehydration from fluid loss, and psychological distress from stigma or embarrassment.^[2]^[3] Prevalence is higher in populations with neuromuscular impairments, underscoring its role as a symptom warranting evaluation to address the root cause and mitigate complications.^[2]

Definition and Physiology

Definition

Drooling, medically termed sialorrhea or ptyalism, is defined as the unintentional escape of saliva from the mouth, often resulting from excessive production, impaired swallowing mechanisms, or diminished oral motor control.^[1] This condition represents a deviation from typical saliva management, where the average daily salivary output in healthy adults ranges from 0.5 to 1.5 liters, most of which is swallowed unconsciously.^[4] Sialorrhea can manifest in various forms, but it is characterized by the saliva's failure to remain contained within the oral cavity. A key distinction exists between anterior and posterior drooling. Anterior drooling involves visible spillage of saliva from the front of the mouth, leading to observable wetness on the chin, lips, or clothing.^[5] In contrast, posterior drooling occurs when saliva flows uncontrollably into the pharynx or hypopharynx, potentially without external signs but increasing risks such as aspiration into the airways.^[6] Common symptoms of drooling include persistent wetness of the chin and clothing from anterior leakage, which can cause social embarrassment and hygiene challenges.^[5] Additionally, it may lead to skin irritation or maceration around the mouth due to prolonged moisture exposure, potentially resulting in secondary infections or rashes.^[7] Speech disturbances can also arise, as excess saliva interferes with articulation and oral clarity. The recognition of drooling as a medical phenomenon dates back to ancient times, with descriptions of excessive salivation and drooling appearing in the works of Hippocrates around 400 BCE, particularly in discussions of neurological conditions like the "sacred disease" (epilepsy).^[8]

Normal Salivary Production and Control

Salivary production occurs primarily through three pairs of major salivary glands: the parotid, submandibular, and sublingual glands, which together account for approximately 92%–95% of the total daily saliva output of 0.5 to 1.5 liters in humans.^[9] The parotid glands, located anterior to the ears between the sternocleidomastoid and masseter muscles, produce a purely serous (watery) secretion rich in enzymes like amylase.^[9] In contrast, the submandibular glands, situated beneath the mandible between the bellies of the digastric muscles, and the sublingual glands, positioned under the floor of the mouth superior to the mylohyoid muscle, generate mixed secretions that are predominantly serous in the submandibular glands and mucinous in the sublingual glands.^[9] Neural regulation of salivary secretion is mediated by the autonomic nervous system, with parasympathetic stimulation via the facial (cranial nerve VII) and glossopharyngeal (cranial nerve IX) nerves promoting increased volume of watery saliva.^[10] Parasympathetic preganglionic fibers from the superior salivatory nucleus travel through the facial nerve to innervate the submandibular and sublingual glands via the submandibular ganglion, while those from the inferior salivatory nucleus use the glossopharyngeal nerve to reach the parotid gland through the otic ganglion; postganglionic fibers act primarily on muscarinic M3 receptors to enhance secretion.^[10] Sympathetic innervation, originating from the superior cervical ganglion and traveling along blood vessels, influences saliva viscosity by stimulating adrenergic receptors with norepinephrine, resulting in a more protein-rich, thicker output, though it contributes less to overall volume compared to parasympathetic activity.^[10] Control of saliva within the oral cavity relies on the swallowing reflex, a coordinated process that contains and propels saliva or a bolus using muscles of the oral and pharyngeal regions.^[11] During the oral preparatory and propulsion phases, the lips seal the anterior oral cavity to prevent anterior leakage, while the tongue elevates and moves posteriorly to form and direct the bolus toward the oropharynx.^[11] In the subsequent pharyngeal phase, triggered by sensory input from cranial nerves IX and X, the pharyngeal constrictor muscles contract sequentially to propel the bolus inferiorly at speeds of 20–40 cm/s, with suprahyoid muscles elevating the hyoid-laryngeal complex to facilitate passage through the upper esophageal sphincter and protect the airway.^[11] Several physiological factors modulate saliva production rates and composition. Hydration status directly affects saliva consistency, as dehydration reduces water content and leads to thicker secretions, whereas adequate fluid intake maintains normal flow.^[12] Dietary components, particularly acidic or sour foods, stimulate increased production through taste receptor activation, aiding in digestion and oral protection.^[12] Circadian rhythms also influence output, with salivary glands exhibiting higher activity and flow during daytime hours and a significant decrease at night, aligning with overall physiological rest cycles.^[12]

Causes

Physiological Causes

Drooling is a common physiological occurrence in infants and young children, stemming from normal developmental stages rather than any underlying disorder. During the first few months of life, infants experience increased saliva production as their salivary glands mature, coinciding with the exploration of their environment through mouthing objects. However, immature oral motor skills—such as underdeveloped swallowing reflexes, weak lip closure, and limited tongue control—prevent effective containment and management of saliva, leading to visible drooling. This typically emerges around 2 to 3 months of age and becomes more noticeable by 5 to 6 months, when saliva flow peaks in preparation for the introduction of solid foods.^[13]^[14] Teething represents a key physiological trigger for heightened drooling in this age group. Tooth eruption, often beginning between 3 and 6 months and continuing through the second year, irritates the gums and stimulates the salivary reflex, resulting in temporary hypersecretion of saliva to soothe the area and aid in lubrication. This response is evolutionarily adaptive, facilitating the transition to chewing, but combined with ongoing oral immaturity, it exacerbates drooling until approximately 2 to 4 years of age, when neuromuscular coordination improves and front teeth emerge to better seal the mouth. Drooling generally resolves spontaneously as these skills mature, with most children achieving full saliva control by age 4.^[15]^[13] The prevalence of physiological drooling is high during infancy and declines progressively with age and oral motor development. No significant gender differences are noted in the occurrence or severity of these normal cases. Situational factors can also induce transient drooling by elevating saliva production; for instance, ingestion of spicy foods activates capsaicin-sensitive receptors in the oral cavity, prompting a protective increase in salivation that may overflow if swallowing is not immediate. If drooling continues beyond typical developmental timelines, such as after age 4, further evaluation may be warranted to rule out other causes.^[16]^[17]

Pathological Causes

Pathological causes of drooling, also known as sialorrhea, primarily arise from underlying medical conditions that disrupt normal salivary control or swallowing mechanisms. These conditions often lead to persistent, excessive saliva accumulation due to impaired neuromuscular function, structural abnormalities, or systemic disturbances, contrasting with transient physiological instances.^[1] Neurological disorders are among the most common pathological contributors to drooling. In cerebral palsy, a condition affecting motor control, drooling occurs in 10-80% of cases due to poor oral muscle coordination and delayed swallowing reflexes, leading to anterior saliva leakage.^[18] Parkinson's disease frequently causes drooling through dysphagia, where reduced swallowing frequency and rigidity in orofacial muscles result in saliva pooling, affecting 70-80% of patients as the disease progresses.^[18] Similarly, stroke can induce acute or chronic drooling by damaging brain areas responsible for swallowing, depending on lesion location.^[19] Amyotrophic lateral sclerosis (ALS) also contributes, with sialorrhea reported in approximately 50% of patients due to bulbar muscle weakness that hinders saliva clearance.^[18] Other neurological and developmental conditions, such as Down syndrome and autism spectrum disorder, can lead to drooling through impaired oral motor control or sensory processing issues affecting swallowing.^[3] Oral and structural issues can exacerbate drooling by mechanically impairing saliva containment or swallowing. Malocclusion, or misalignment of the teeth and jaws, promotes an open-mouth posture that facilitates saliva escape, often compounding neurological deficits.^[20] Enlarged tonsils, typically from chronic infection or hypertrophy, cause painful swallowing and mouth breathing, resulting in drooling as a secondary symptom.^[21] Swollen adenoids or poor dentition can similarly contribute by obstructing nasal breathing or hindering proper mouth closure.^[3] Esophageal strictures, narrowings of the esophagus often from scarring or inflammation, lead to dysphagia severe enough to cause drooling of saliva, particularly in pediatric cases where secretions cannot be managed.^[22] Infections and allergies may induce drooling by causing nasal congestion, mouth breathing, or increased saliva production as a response to irritation.^[3] Systemic conditions and iatrogenic factors further drive pathological drooling. Gastroesophageal reflux disease (GERD) stimulates excess saliva production via water brash, where esophageal acid irritation triggers hypersalivation as a protective response, potentially leading to overflow.^[23] Certain medications, notably antipsychotics like clozapine, induce sialorrhea by enhancing cholinergic activity or disrupting salivary regulation, affecting a significant portion of users.^[24] Drooling from pathological causes shows notable prevalence in specific populations, such as those with cerebral palsy, through combined neurological and structural impairments. Recent studies have highlighted emerging links, such as post-COVID-19 dysphagia contributing to drooling via persistent bulbar dysfunction, as observed in 2023 case reports of recovery with targeted interventions.^[25]

Diagnosis and Evaluation

Clinical Assessment

The clinical assessment of drooling, also known as sialorrhea, begins with a detailed history taking to determine the onset and duration of symptoms, which helps distinguish between acute and chronic presentations. Healthcare providers inquire about the age at which drooling started, its progression over time, and any associated symptoms such as choking, aspiration risks, speech or swallowing difficulties, or changes in oral intake. Family history, including developmental milestones and any genetic or neurological conditions, is also elicited to identify potential underlying factors, particularly in pediatric patients.^[26]^[27]^[13] Physical examination focuses on observing the patient's overall posture, head control, and perioral skin condition for signs of irritation or maceration due to chronic moisture exposure. Intraoral assessment evaluates oral hygiene, dental status, tongue size and mobility, muscle tone in the face and neck, and the gag reflex to detect impairments in swallowing or sensory function. Severity is quantified using validated scales, such as the Drooling Impact Scale (DIS), a 10-item parent-reported questionnaire assessing the frequency and impact of drooling on daily activities like clothing changes and social interactions, or the Teacher Drooling Scale (TDS), a 5-point observer-rated tool measuring drooling frequency from "no drooling" to "constant drooling." These scales provide objective benchmarks for initial severity and monitor changes over time.^[28]^[29]^[30]^[31] Differential diagnosis during assessment involves evaluating patient age, comorbidities, and symptom acuity to rule out acute causes like infections versus chronic ones often linked to neurological impairments. For instance, acute drooling in infants may relate to teething or transient infections, while persistent drooling beyond age 4 years in children with developmental delays suggests pathological origins such as cerebral palsy. This step guides whether further specialist input is needed early.^[13]^[29]^[28] A multidisciplinary team approach is integral from the outset, involving speech-language pathologists for oromotor evaluation, neurologists for underlying neurological assessment, and sometimes occupational therapists to address postural contributions to drooling. This collaborative evaluation ensures comprehensive identification of contributing factors, such as poor head control or sensory processing issues, without delaying intervention planning.^[29]^[31]^[32]

Diagnostic Investigations

Diagnostic investigations for drooling, also known as sialorrhea, involve objective tests to identify underlying causes such as swallowing impairments or neurological abnormalities, building on initial clinical assessments. The videofluoroscopic swallow study (VFSS), a radiographic imaging technique, visualizes the oral and pharyngeal phases of swallowing in real-time using barium-contrast materials to detect aspiration risks and dysphagia severity, which are common contributors to drooling in conditions like Parkinson's disease. VFSS has demonstrated a direct correlation between dysphagia extent and drooling severity, aiding in confirming posterior oral leakage or inefficient bolus clearance.^[33]^[34] Magnetic resonance imaging (MRI) of the brain is employed to detect neurological lesions or structural abnormalities that may impair cranial nerve function and lead to drooling, particularly in cases suggestive of central nervous system involvement. For instance, MRI can reveal pathologies such as brainstem lesions or cranial nerve damage associated with hypersalivation or swallowing dysfunction in neurological disorders. This modality is recommended for patients with suspected cranial nerve etiologies to clarify underlying brain abnormalities.^[35]^[36] Salivary flow tests quantitatively assess glandular output to differentiate hypersecretion from impaired control as the primary cause of drooling. Salivary gland scintigraphy, a functional imaging technique, involves injecting a radiotracer to evaluate uptake and stimulated excretion in the parotid and submandibular glands, helping to identify dysfunction such as delayed uptake or reduced excretion response that may contribute to sialorrhea.^[37]^[38] Fiberoptic endoscopic evaluation of swallowing (FEES) uses a flexible endoscope passed through the nasal passage to directly observe pharyngeal structures during swallowing, effectively detecting posterior drooling, residue, or silent aspiration not visible in anterior assessments. In neurological conditions like Parkinson's disease, FEES identifies saliva pooling or penetration risks by staining oral contents, offering bedside applicability without radiation exposure.^[39]^[40] Recent advancements since 2022 incorporate artificial intelligence (AI) for automated analysis of VFSS and FEES videos, enhancing diagnostic precision by detecting subtle swallowing anomalies linked to drooling. AI models process entire swallow sequences to quantify dysphagia parameters, such as aspiration events or bolus flow disruptions, with high accuracy in supporting clinical decisions for sialorrhea management. These tools, including computer-aided diagnosis systems for FEES, address variability in manual interpretations and are emerging as adjuncts in neurological evaluations.^[41]^[42]^[43]

Management and Treatment

Non-Medical Interventions

Non-medical interventions for drooling, also known as sialorrhea, primarily involve behavioral, therapeutic, and supportive strategies aimed at enhancing oral control, swallowing efficiency, and overall management without relying on medications or surgery. These approaches are often first-line treatments, particularly for mild to moderate cases, and are tailored to the individual's underlying causes, such as impaired oral motor function or posture issues. They emphasize patient or caregiver involvement to promote long-term adherence and improvement in daily functioning. Behavioral therapies form a cornerstone of non-medical management, focusing on training to improve voluntary control over saliva. Oral motor exercises target strengthening and coordination of the lips, tongue, jaw, and facial muscles to facilitate better lip closure and reduce anterior saliva leakage. For instance, exercises such as lip pursing, tongue protrusion, and side-to-side movements can enhance muscle tone and endurance, with protocols often delivered by speech-language pathologists over several weeks.^[27]^[44] Biofeedback training complements these by providing real-time sensory feedback, such as visual or auditory cues, to increase awareness of drooling and encourage more frequent swallowing. Studies have shown that biofeedback, combined with behavioral reinforcement like rewards for dry periods, can significantly decrease drooling rates in individuals with mild neurological impairments, leading to improved swallow frequency and reduced saliva accumulation.^[45]^[26] Speech-language pathology interventions incorporate specialized techniques to prompt reflexive swallowing and sensory awareness. One effective method involves sour taste stimulation, where acidic solutions like citric or acetic acid are introduced to the oral cavity to elicit stronger pharyngeal reflexes and facilitate swallowing onset. This approach, often integrated into therapy sessions, leverages the heightened neural activation from sour stimuli to improve saliva clearance without invasive measures.^[46] Assistive devices provide practical support for immediate saliva management and posture optimization. Absorbent bibs with waterproof backing help contain drool, preventing clothing soiling and skin irritation, while being easily replaceable for hygiene maintenance.^[14] Portable suction devices, such as oral aspirators, allow for on-demand removal of excess saliva, particularly useful in cases of reduced swallowing ability, and can be operated by caregivers or independently if feasible.^[47] Positioning aids, including supportive chairs or wedges, promote upright posture and head alignment to minimize forward head tilt, which exacerbates drooling by allowing saliva to escape the mouth. Correcting posture in this manner enhances gravitational flow toward the pharynx, supporting natural swallowing mechanics.^[48]^[49] Caregiver education plays a vital role in sustaining these interventions through structured guidance on daily routines. Training programs emphasize oral hygiene practices, such as frequent gentle wiping, teeth brushing, and monitoring for perioral dermatitis caused by prolonged moisture exposure, to prevent secondary skin complications. Evidence indicates that such education significantly boosts caregiver confidence, leading to consistent application of techniques and observable improvements in drooling control. In mild cases, comprehensive non-medical strategies, including behavioral therapies and education, have demonstrated efficacy, with dry periods increasing from baseline rates of around 10% to 50-60% post-intervention.^[50]^[51]

Medical and Surgical Options

Medical and surgical options are typically considered for persistent drooling that does not respond adequately to non-medical interventions, particularly in cases associated with neurological conditions such as cerebral palsy. Pharmacological treatments primarily involve anticholinergic medications that inhibit salivary gland secretion, with glycopyrrolate being a commonly used agent due to its quaternary ammonium structure, which limits central nervous system penetration and reduces systemic side effects compared to alternatives like scopolamine.^[52] Oral glycopyrrolate has demonstrated efficacy in reducing drooling severity in children with neurodevelopmental disabilities, with response rates ranging from 52% to 95% across multiple studies, as evidenced by improvements in standardized drooling scales such as the Teacher Drooling Scale.^[53] Typical dosing starts at 0.02 mg/kg twice daily, titrated up to 0.1 mg/kg per dose, and it is indicated for chronic moderate-to-severe sialorrhea in pediatric patients aged 3 years and older with conditions like cerebral palsy.^[54] Botulinum toxin type A (BoNT-A) injections into the parotid and submandibular salivary glands represent another key pharmacological intervention, acting by temporarily blocking acetylcholine release at nerve endings to reduce saliva production. These injections are particularly effective for drooling in children with cerebral palsy, where meta-analyses indicate significant reductions in drooling severity (standardized mean difference: -2.07; 95% CI: -2.91 to -1.23) and response rates approaching 70% in cohorts predominantly comprising cerebral palsy patients (approximately 69% of study participants).^[55] The effects typically onset within 1-2 weeks and last 3-6 months, necessitating repeat injections for sustained management.^[56] Common dosages range from 15-50 units per parotid gland and 10-35 units per submandibular gland, with ultrasound guidance often used to improve precision and minimize complications like dysphagia, which occurs in a minority of cases.^[57] For severe, refractory drooling, surgical techniques such as submandibular duct relocation or submandibular gland excision are employed, often in combination with parotid duct rerouting to redirect saliva flow posteriorly and reduce anterior drooling. Submandibular duct relocation involves transposing the ducts to the posterior oral cavity, achieving subjective success rates of 84.4% (95% CI: 77.7%-91.1%) in pediatric patients based on meta-analytic evidence from multiple cohort studies.^[58] Submandibular gland excision, typically performed bilaterally via a transcervical approach, yields even higher success rates of 87.8% (95% CI: 80.5%-95.1%) for long-term drooling control in neurodisabled children, with effects persisting for years in most cases.^[58] These procedures are reserved for cases unresponsive to conservative measures, with potential complications including ranula formation (requiring additional sublingual gland excision in about 8% of patients) or transient facial nerve weakness.^[59] Emerging therapies include low-dose external beam radiation to the major salivary glands, which has gained attention since the 2010s for refractory sialorrhea, particularly in adults with parkinsonism or amyotrophic lateral sclerosis. Radiation (typically 6-13 Gy in fractionated doses to parotid or submandibular glands) significantly reduces drooling severity, with effects lasting at least 12 months and comparable efficacy between gland targets.^[60] However, it carries risks of side effects such as xerostomia (dry mouth) and thickened saliva, affecting up to 33% of patients temporarily, alongside rare concerns for long-term secondary malignancies.^[60] Recent meta-analyses up to 2024 underscore the overall efficacy of these interventions, particularly BoNT-A in cerebral palsy populations, supporting their role in expanding beyond limited traditional options.^[55] As of 2025, additional emerging pharmacological options include newer formulations of botulinum neurotoxin type A, such as daxibotulinumtoxinA, which has shown successful treatment of sialorrhea with a favorable side effect profile, and incobotulinumtoxinA, demonstrating efficacy and good tolerability in chronic cases, including in Japan.^[61]^[62] For Parkinson's disease-related drooling, dihydroergotoxine mesylate has demonstrated safe mid- to long-term efficacy in improving salivation.^[63] A November 2024 study further supports the efficacy of submandibular gland excision in reducing drooling and aspiration risk compared to alternatives like duct closure or Botox injections.^[64]

Complications and Impacts

Health Complications

Uncontrolled drooling, or sialorrhea, can lead to several physical health complications, primarily affecting the oral cavity, skin, and respiratory system. Prolonged exposure to saliva causes maceration of the perioral skin, where constant moisture softens and breaks down the skin barrier, increasing vulnerability to irritation and secondary infections.^[13] This moisture also promotes perioral dermatitis, a common inflammatory condition characterized by redness, scaling, and discomfort around the mouth and chin.^[65] Additionally, the persistent damp environment elevates the risk of dental caries, as saliva's carbohydrates provide a substrate for bacterial growth, particularly impacting anterior teeth and gingival health.^[66] Respiratory complications arise mainly from posterior sialorrhea, where saliva pools in the oropharynx and is aspirated into the airways, leading to aspiration pneumonia—a serious infection that can cause coughing, gagging, and potentially life-threatening respiratory distress.^[28] In individuals with severe neurological conditions, such as cerebral palsy or stroke, this risk is heightened, with studies indicating increased incidence of aspiration pneumonia.^[67] Posterior drooling exacerbates this by impairing swallowing coordination, contributing to recurrent lower respiratory tract infections.^[19] Nutritionally, excessive drooling is associated with dehydration due to fluid loss from constant saliva spillage and inadequate oral intake.^[26] In cases involving swallowing difficulties, patients may develop an aversion to eating, further reducing caloric and fluid consumption and leading to malnutrition or electrolyte imbalances.^[68] Long-term data from children with cerebral palsy reveal elevated infection rates linked to sialorrhea, with posterior drooling identified as a key factor in progressive respiratory morbidity, including higher incidences of pneumonia and aspiration events.^[69] Recent studies emphasize that up to 44% of these children experience sialorrhea, underscoring the need for targeted interventions to mitigate these ongoing health risks.^[70] Drooling often leads to significant stigma and social isolation, particularly among school-aged children, where it can result in peer avoidance and bullying that undermine self-esteem. In a 2024 study of children and young people with neurodevelopmental disabilities and a developmental age of 6 years or older, 49% of parents reported that their children were avoided by peers due to anterior drooling, while 28% noted avoidance by adults; additionally, 25% of the children expressed dissatisfaction with their physical appearance linked to drooling, and 21% reported negative feelings about peer acceptance.^[71] These experiences contribute to broader emotional distress, including a 37.5% average reduction in scores related to social well-being and acceptance among children with cerebral palsy, as measured by the Cerebral Palsy Quality of Life-Child questionnaire in a 2023 cross-sectional study of 100 participants.^[72] Such stigmatization frequently exacerbates feelings of low self-worth and withdrawal from social activities, hindering developmental milestones like forming friendships. In adults, particularly those with neurological conditions such as Parkinson's disease, visible drooling creates social barriers and erodes confidence, often limiting professional and interpersonal engagements. A 2025 qualitative study of individuals with Parkinson's disease found that drooling induced self-consciousness and reduced self-confidence, leading to social withdrawal and avoidance of activities like dining out or exercising; participants described feeling "beaten" or less outgoing, with some noting direct impacts on employment, such as embarrassment while teaching or concerns about client perceptions in tourism roles.^[73] This aligns with broader evidence from a 2019 review of sialorrhea in chronic neurological conditions, where drooling was associated with increased stigma, anxiety, and depression, further compromising social functioning and daily interactions.^[19] The emotional strain on caregivers managing drooling-related hygiene adds another layer of psychological burden, often resulting in heightened anxiety and reduced family quality of life. In a 2025 cross-sectional study of Parkinson's disease patients and their caregivers, those caring for individuals with severe drooling reported significantly higher scores on the Zarit Burden Interview (median 31.0) compared to mild (22.0) or no drooling cases (7.0), with correlations to increased emotional distress tied to disease duration and severity.^[74] Similarly, a 2023 study on sialorrhea in children with cerebral palsy highlighted emotional strain on families from constant clothing changes and social stigma management.^[72] Psychological support, including counseling within multidisciplinary interventions, can mitigate these effects; for instance, 2023 quality-of-life assessments in cerebral palsy cohorts showed improvements in social integration scores following holistic support that addressed emotional impacts alongside physical management.^[72]

Contexts and Variations

In Pediatrics

Drooling is a normal physiological phenomenon in infants and young children, emerging around 2 to 4 months of age as salivary production increases and oral motor skills are still maturing. It typically peaks between 6 and 18 months, often coinciding with teething and the emergence of teeth, when children produce more saliva but lack full control over swallowing and lip closure. In typically developing children, drooling gradually decreases after 18 to 24 months as oral musculature strengthens, and it resolves in the vast majority by age 4 years, with persistent cases occurring in only about 0.5% of the general pediatric population.^[13]^[14]^[75] Common etiologies of drooling in children beyond these normative patterns include developmental delays in oral-motor function, which impair the coordination needed for effective saliva management. Allergies and upper respiratory issues frequently contribute by promoting mouth breathing through nasal congestion, leading to an open-mouth posture that exacerbates saliva spillage. These factors are particularly relevant in otherwise healthy children, distinguishing them from more severe neurological causes.^[20]^[3]^[76] Tailored management in pediatrics prioritizes age-appropriate, minimally invasive strategies to support natural resolution. For teething-associated drooling, topical gels containing natural soothing agents like chamomile can alleviate gum irritation and reduce excessive salivation, though benzocaine-based products are discouraged in infants under 2 years due to risks of methemoglobinemia. In cases of chronic drooling starting from age 2 years, botulinum toxin type A injections into the salivary glands offer a targeted option, with FDA approval for pediatric use (e.g., incobotulinumtoxinA) established since 2020 for children aged 2 and older, providing relief for 3 to 6 months per treatment.^[77]^[78]^[79] Monitoring drooling in relation to growth milestones is essential, as prolonged issues can signal delays in speech development by affecting tongue and lip control critical for articulation. Recent 2024 pediatric guidelines advocate for early intervention through multidisciplinary teams, including speech-language pathologists, to integrate drooling management with broader developmental support and prevent long-term impacts on communication skills.^[80]^[32]

In Neurological Conditions

Drooling, or sialorrhea, is a prevalent symptom in various neurological conditions, arising primarily from disruptions in the neural control of oral motor function and swallowing. Cerebral palsy (CP) represents the most common associated disorder, with prevalence estimates ranging from 10% to 58% among affected individuals, often leading to chronic sialorrhea due to impaired muscle coordination.^[81] Amyotrophic lateral sclerosis (ALS) frequently involves bulbar-onset symptoms, where up to 50% of patients experience drooling as disease advances, exacerbated by progressive muscle weakness.^[82] In multiple sclerosis (MS), drooling occurs particularly with bulbar involvement, correlating with dysphagia where corticobulbar tract lesions impair swallowing reflexes.^[83] Parkinson's disease (PD) also contributes significantly, with drooling reported in 32-74% of patients, often worsening alongside motor fluctuations.^[19] The underlying mechanisms in these conditions typically involve impaired function of cranial nerves, particularly the glossopharyngeal, vagus, and hypoglossal nerves, which govern swallowing and oral containment of saliva. This results in weakened pharyngeal muscles and reduced swallowing efficiency, causing saliva to accumulate and spill anteriorly rather than being cleared posteriorly. In ALS and bulbar MS, bulbar weakness leads to dysphagia and dysarthria, pooling secretions in the mouth without increased saliva production.^[84] Similarly, in CP and PD, spasticity or rigidity disrupts the coordinated oro-motor sequence, promoting anterior drooling over effective bolus propulsion.^[85] Management in neurological contexts emphasizes specialized interventions tailored to disease-specific pathophysiology. Intraglandular injections of botulinum toxin into salivary glands, such as the submandibular and parotid, have demonstrated efficacy in reducing drooling in PD, with phase 3 trials showing significant decreases in saliva production and subjective drooling severity compared to placebo.^[86] Multidisciplinary neuro-rehabilitation approaches, involving speech-language pathologists, neurologists, and occupational therapists, are recommended for optimizing oral motor control through targeted exercises, positioning techniques, and biofeedback, particularly in progressive conditions like ALS and MS.^[75] Prognosis for drooling in these disorders generally aligns with overall disease progression, often worsening as neural degeneration advances and swallowing function deteriorates further. In PD and ALS, sialorrhea correlates with declining quality of life and increased caregiver burden, progressing from intermittent to constant in advanced stages.^[87]

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Overproduction of saliva can result from certain medications, especially of the antipsychotic type, vitamin deficiencies, and gastroesophageal reflux (5).<|control11|><|separator|>
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2 years of age for the treatment of chronic sialorrhea · 2 years of age for the treatment of upper limb spasticity · 18 years of age for the ...
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Drooling may be Associated with Dysphagia Symptoms in Multiple ...
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Management of Sialorrhea in ALS
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Safety and Efficacy of RimabotulinumtoxinB for Treatment of ...
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