This factsheet is aimed at those affected by MSA who are experiencing difficulties with saliva control. It provides information about the possible problems people face with saliva control and gives suggestions on what can be done to manage the symptoms.
It is important to get a referral to a Speech and Language Therapist (SLT) at the first signs of any difficulties with saliva control. This can be an indication that swallow co-ordination is not working as effectively as it should. The SLT is the best person to assess swallow and give advice about the most appropriate way to manage the difficulties.
Possible problems
Some people may experience discomfort and embarrassment due to reduced saliva control. Saliva plays an important function in the mouth. It helps break down food and protects the mouth from drying out and cracking and helps maintain good dental health. However, too much or too little saliva can cause problems with eating and drinking and with speech. If saliva accidentally enters the lungs it can cause chest infections.
We all produce about a litre and a half of saliva every day, which is then swallowed. People with MSA can have a reduced swallow reflex and a difficulty in moving saliva from the front to the back of the mouth. If the nerves that control our saliva production, swallow and/or ability to close our mouths are not working properly, then saliva can pool and spill out over the lips.
In addition, saliva may be thick and difficult to swallow, and the use of some medications can cause both a drying up of saliva and a dry mouth.
What can be done?
The following advice may help depending on the nature of the saliva problem. The advice is based on medical understanding, commonly held knowledge and strategies that have helped people before.
Too much saliva
If the problem is too much saliva, then a few options are available.
Food and Drink:
Some foods and drinks can help reduce saliva production. You might try:
- Ginger tea – this has a drying effect on the mouth; sucking pieces of dried ginger may help if there is no risk of choking
- Dark grape juice can help dry up thin, runny saliva
- Sage tea
- Chewing gum can help stimulate regular swallow of saliva too.
- Sipping water if safe to do so can prompt swallowing and help clear pooled saliva
Posture:
- Muscle weakness can have an effect on posture and positioning, which can cause difficulties with saliva control.
- In some cases, improving your posture can improve the problem, so try to keep your head as upright as possible at all times.
- Physiotherapists and Occupational Therapists can offer advice on exercises or aids, such as seating support and neck collars that may help with posture and positioning. They can also help with techniques to manage secretions and provide aids such as cough assist machines and suctioning if appropriate.
Routine:
- Remind yourself to keep your mouth closed when you are reading, listening or watching television.
- Keep some tissues or a towel handy. Dabbing at saliva rather than wiping it away will cause less irritation to the skin. Vaseline or a barrier cream may be required at the corners of the mouth and on the chin to prevent them becoming sore.
- Make a point of swallowing your saliva at regular intervals e.g. every 2 minutes – your Speech Therapist may recommend using a swallow prompt, if you are forgetting to swallow. This can remind you to swallow by using an audible sound via the speech swallow prompt app that can be downloaded onto your smart phone. Parkinson’s UK also sell a vibrating wrist band style watch that can be used as a swallow prompt.
- https://shop.parkinsons.org.uk/collections/everyday-living-aids-1/products/vibrating-watch-reminder
- Always ensure the mouth is as clean as possible; good oral care and hygiene will reduce the amount of bacteria in the mouth. Using an electric toothbrush if hand and wrist movement is difficult can be helpful, also a baby’s toothbrush that has a smaller head and is softer to clean the tongue and gums, might make this easier.
Exercises:
Your Speech and Language Therapist (SLT) can advise you about a range of exercises to promote swallow and lip closure such as:
- Push lips forward as if saying ‘oo’
- Spread lips as if saying ‘ee’
- Repeat ‘oo’ ‘ee’ 6 times
- Puff air into your cheeks for as long as possible
- Press your lips tightly together as if saying ‘mm’.
Do this series of exercises several times a day if you can and talk to your SLT about them. A SLT can assess your swallow, identify the cause of any issues, advise on specific exercises and treatments and monitor and review you regularly.
Over the counter remedies:
- Be cautious with over the counter remedies such as sea-sickness tablets or cough and cold remedies, which claim to dry up saliva.
- For some people with MSA these can give temporary relief, but in others can cause side effects. Discuss this with your SLT, MSA Health Care Specialist, consultant, GP or Pharmacist before proceeding.
Medication:
The following may be prescribed by your GP or specialist.
- Atropine eye drops used under the tongue are found to be beneficial in most cases. These are used because a side effect of the eye drops is the drying of secretions. They are NOT to be used in the eyes! One to two drops up to four times a day. Most people find them beneficial about 30 minutes before mealtimes. The first few times you use these you will need to remove excess moisture from your mouth with a tissue or cotton handkerchief, otherwise the drop of atropine will be lost in the saliva. Once you have used the drops a few times you will learn how long they are effective for you before your mouth is too moist again and can time the next dose to go in 30-60 minutes before this point. They can take a few weeks to become effective, so persevere with them. Most GPs will prescribe these drops for this purpose though they are not obliged to as this use is not what they were licensed for.
- Glycopyrronium can be prescribed to dry out the mouth providing some temporary relief. This comes in tablet or liquid form and is usually taken up to three times a day.
- Other medications can have the beneficial side effect of reducing the amount of saliva in the mouth. An example of this is Amitriptyline, which is taken at night. It is an antidepressant that is also used for pain management and to assist sleep,
- Hyoscine is commonly used for drying of saliva, often in a patch form. This is probably the most commonly used medication for saliva problems and so may be the choice of your GP – if you are prescribed this and experience any excessive drowsiness, confusion or hallucinations (sometimes more common in elderly people and those with MSA) then remove the patch immediately and inform your GP.
- Botox injections into the salivary glands may be given by the neurologist or a specialist familiar with doing this procedure. These can be effective for some patients and treatment usually lasts 3-4 months, at which point the injection can be repeated.
- If all the above are ineffective then some neurologists may try Ipratropium bromide – known as Atrovent inhaler – this comes as a pump inhaler but can be sprayed directly into the mouth 2-3 times a day, again it is most help 30 minutes before meals and at bedtime.
Some People with MSA may not tolerate all these medications and your GP or specialist will be able to advise further after considering your full medical history.
Too little saliva
If the problem is too little saliva, then a few options are available.
Food and Drink:
- Some foods can make dryness in the mouth worse. You can ask for a referral to a dietician via your GP for dietary advice e.g. avoiding alcohol and caffeine and advising on natural products that can help
- Ensure you are drinking enough fluids and take frequent sips of water
- Avoid alcohol and smoking as these can both increase dryness
- Chewing gum or sucking sweets, if safe to do so, can stimulate saliva production
- Sucking on ice cubes can be helpful and refreshing.
Medication:
- Discuss the use of artificial saliva sprays or gels (available on prescription) or alternative medication, with your GP or Neurologist
- Medicated mouthwashes, available on prescription from your GP, can help with maintaining good oral hygiene.
Other things that may help:
- Avoid mouthwashes that contain alcohol
- Pay careful attention to oral hygiene
- Use lip balm or apply Vaseline to lips and in the corners of your mouth regularly
- Remove and clean dentures at night.
Thick saliva
If the problem you are having is with thick saliva then the following may help:
Food and Drink:
- Ensure you are drinking enough liquids. You should aim for 1½ to 2 litres a day.
- Avoid caffeinated drinks and alcohol.
- Pineapple juice, pureed pineapple or chewing pineapple chunks or drinking papaya juice will help break down thick saliva
- Suck on crushed ice.
Medication
- Mucolytic medications, such as Carbocisteine, can be used for thick saliva.
Other things that may help
- Steam inhalation/humidification/nebulisers can be helpful. Discuss these with your GP, nurse or pharmacist
- A water-based gel can be spread over the lips and inside the mouth to maintain moisture at night.
- Cleaning around your mouth with a soft baby toothbrush and water or small amount of toothpaste may also help and spitting out the thick saliva.
- If you have very thick saliva collecting in the back of your throat and you cannot swallow it or bring it forward to clear from your mouth with any of the treatments above, then speak to your GP or District Nurse as they may be able to provide you with a suction machine. Your physiotherapist will also be able to give you techniques and equipment to assist with coughing.
- Important to visit the dentist for regular dental checks.
If you are concerned about anything you have read in this factsheet, then please get in touch with your MSA Health Care Specialists.
