Current Series: Management of Sialorrhea in Parkinson Disease

Stuart Isaacson, MD: Hello. Thank you for joining this NeurologyLive® Peers & Perspectives presentation titled “Management of Sialorrhea in Parkinson Disease.”

I am Dr Stuart Isaacson, the director of the Parkinson’s Disease and Movement Disorders Center in Boca Raton, Florida.

Sialorrhea is a common symptom of Parkinson disease that can cause both physical and social consequences and impact the patient’s quality of life. Today we are going to talk about some of the challenges of identifying sialorrhea and current treatment options to best manage it in Parkinson disease.

To discuss these challenges, I am joined by Dr Richard Trosch, who is a neurologist specializing in movement disorders at The Parkinson’s and Movement Disorder Center at Michigan Healthcare Professionals in Farmington Hills, Michigan.

Thank you so much for joining us. Let’s begin.

Richard, can you tell us about this problem, sialorrhea in Parkinson disease. How common is it? Why should we care about sialorrhea in Parkinson disease? There are so many other problems. Why is this a problem we’re talking about today?

Richard M. Trosch, MD: First, it’s a common problem. Most patients with PD [Parkinson disease] drool, and most have sialorrhea. It’s thought that about 75% have drooling. It’s not all severe. A significant number will have severe drooling, and this can be problematic. The anterior drooling—which is drooling that comes forward or oral incontinence in which the saliva is becoming beyond the lip and causing excoriation—can cause intimacy problems and affect speech. But we’re also concerned with the posterior drooling. That’s the saliva passing over the tongue into the oral pharynx and possibly into the lungs, which can be a cause of aspiration pneumonia. Particularly at night, when patients lie down, a lot of patients will give a history that when they lie down at night, they cough. And they’re coughing because they’re aspirating their secretions, and aspiration pneumonia is still the No. 1 cause of death in Parkinson. Posterior drooling is a very serious symptom.

Stuart Isaacson, MD: Is it due to too much production of saliva? Is that why people have this type of drooling?

Richard M. Trosch, MD: Actually, in PD, the production of saliva is reduced versus normal controls. Their problem is clearance. Parkinson patients don’t swallow as often, and we’re always producing saliva. We make about a liter and a half a day, but we’re constantly swallowing the saliva. But with Parkinson there’s reduced swallowing but also impaired swallowing. That’s why so many of these patients with sialorrhea also have dysphagia because there’s impaired swallowing. If it isn’t clear, the saliva pools. It follows gravity. If the head is down, it comes forward, and we’re going to call that anterior drooling. If the head is back, it goes back over the tongue into the lower pharynx to the isthmus, and they may have aspiration.

Stuart Isaacson, MD: We think about this problem with drooling overnight on the pillow. This can be an early sign of early diagnosis, and certainly patients very advanced may have more drooling, especially posterior problems as well as anterior. But where in the spectrum of the disease do you start paying attention to it?

Richard M. Trosch, MD: That’s a good question. I used to think that once it’s getting on their clothing, they’re really not managing it. Or if it’s evident because you see the patient who comes in your clinic and they’re carrying a tissue, and they’re constantly dabbing the corners of their mouth, or you see drool on their chin. That’s probably pretty severe. But there are studies suggesting that patients who have this nocturnal sialorrhea, where they don’t drool during the day but their pillow is wet when they wake up in the morning; they’re probably having episodic aspiration as well. That’s probably the point where we need to get involved. If someone says, “Well, I have a little extra saliva in my mouth; I don’t drool,” I don’t know that I need to treat that person. But if they wake up and the pillow is wet and there’s obvious drooling during the daytime or their clothing is wet, I think we should intervene with those patients.