Saliva problems in MND

The salivary glands produce two different types of secretions: thin, watery saliva and thick mucus.Phlegm is a thick mucus secreted by the membranes of the respiratory passages. Someone with MND may experience thin, runny saliva that drools out of the mouth, thick tenacious saliva or phlegm. Thick saliva and phlegm can be difficult to clear.Some people may experience all of these.

Thin, watery saliva

People with MND may find they experience pooling of large amounts of thin watery saliva, which can cause drooling. Although a normal amount of saliva is produced by those with MND, around two to three pints every day, excessive saliva (sialorrhea) is a commonly reported symptom.In most cases, saliva problems are the result of poor saliva control, caused by poor lip seal and/or dysphagia. People who have MND may have weak muscles around the mouth, tongue and throat. This can make it more difficult to manage saliva, both in the mouth and during swallowing.

Thick, tenacious saliva, mucus and phlegm

Others complain more of thickened mucus in the mouth and throat, which is difficult to swallow, or phlegm in the airways, which is difficult to cough up due to weakened respiratory muscles and an ineffective cough.Thick mucus can build up in the mouth and at the back of the throat of someone with MND due to:dehydrationmouth breathing or open mouth posture, which can lead to evaporation of saliva.This may produce stringy mucus and cause airways to become blocked. This can be very distressing for the person with MND and those who care for them.

Dry mouth

Some people will experience a dry mouth, which may be caused by the medication they are taking, thrush, a coated tongue, insufficient fluids or breathing through the mouth.

The consultant or specialist nurse will usually manage saliva problems, either with:

• self-help techniques
• prescriptions
• organising equipment/treatment.

This may vary where the specialist centre is not within easy reach. A speech and language therapist or physiotherapist may be able to provide suggestions or strategies to help with saliva control.

A speech and language therapist can:

• help to identify any problems that may be present. These may include poor lip seal and/or weakness in oral and facial muscles or the tongue. All of these can contribute to problems with saliva management
• give advice on different swallowing techniques that may make swallowing easier.

A physiotherapist can give advice on:

• cough management techniques, which may help to cough up thick, tenacious saliva.
• postural problems and ways to alter the person’s position. In some cases, improving posture may help to control the flow of saliva.

Neck weakness and a drooping posture can cause the head to tilt forward, and saliva may flow through the lips before it can be swallowed head supports or neck collars, which may improve the posture of the person with MND.

If a person with MND has problems with saliva, assess the volume and viscosity of the saliva and the person’s respiratory function, swallowing, diet, posture and oral care. If a person with MND has problems with drooling of saliva (sialorrhoea), provide advice on swallowing, diet, posture, positioning, oral care and suctioning.

Key actions
Medication should always be prescribed by a doctor or a professional trained as a prescriber.
Before medication is prescribed by an appropriate professional, the problem should be properly assessed. This is because medications that can ‘dry up’ or reduce watery saliva may lead to thick, tenacious saliva or can worsen the situation if saliva is already thick.

Other medicines, including those available without a prescription, should never be taken without consulting a doctor, as there may be contraindications.
Some people with MND will have an enteral feeding tube. Medication can sometimes be given through the tube, but before putting any medication through, check with a pharmacist that it won’t harden or clog the tube, or affect how well the drug works.

The following medication recommendations are from the NICE guideline on MND. For dosages please refer to British National Formulary (BNF).

• Consider a trial of antimuscarinic medicine as the first-line treatment, eg  hyoscine (tablets or transdermal patches – be aware of the possible side effect of causing confusion in the elderly) glycopyrronium bromide (glycopyrrolate).
• Consider glycopyrrolate as the first-line treatment for sialorrhoea in people with MND who have cognitive impairment, because it has fewer central nervous system side effects.
• If first-line treatment for sialorrhoea is not effective, not tolerated or is contraindicated, consider referral to a specialist service for Botulinum toxin A.

Be aware that treatment with Botulinum Toxin A may have the side effect of increasing dysphagia, so some suggest only resorting to botulinum toxin injections if the person already has enteral feeding in situ. Botulinum toxin should only be administered by specialist practitioners

Radiotherapy
Another possible treatment for excessive, watery saliva is the use of radiotherapy to destroy part of the salivary glands.

Suction
Portable oral suction units are helpful if saliva builds up in the mouth.

• Review all current medicines, especially any treatments for sialorrhoea.
• Provide advice on swallowing, diet, posture, positioning, suctioning, hydration and pay attention to oral hygiene – consult district nurse.
• Consider treatment with humidification, nebulisers and carbocisteine. Carbocisteine is available as capsules or liquid, which can be administered via a feeding tube.

• Dosage of medication should be checked by a prescribing professional and changed if needed.
• Preparations such as artificial saliva sprays or gels, for example Aquoral, Biotene Oralbalance or Xerotin, can help to relieve a dry mouth. They also help to reduce odour-causing bacteria. These treatments are given using a swab around the mouth before meals or at bedtime. Some of these items are available without a prescription.
• Oral hygiene should also be checked. A district nurse may be able to help with this. The teeth, tongue and gum margins should be cleaned regularly and especially before oral medication is given.
• The amount of fluid taken in by the person with MND should be increased, whether orally or through a feeding tube. A dietitian can advise on ways to increase fluid intake.
• Some people have found that, particularly at night, rapeseed or groundnut oil (where appropriate) or ghee can be used as a lubricant when swabbed around the mouth.