Saliva consists of two components, a thin watery secretion and a thick mucus.  These are produced by different salivary glands.  Treatment tends to affect these two components differently and can cause the paradoxical problem of reducing saliva production but producing thick mucus in the throat that is difficult to cough up.

Treatment requires a logical and pragmatic approach.  Pharmacological treatments only work in 50% of cases and even then often become less effective over time.

Treat local factors which may be exacerbating the sialorrhoea:

• Address dental hygiene.
• Treat associated dermatitis with mild steroids, antibiotics, emolients or barrier creams.
• Treat sore gums and mouth ulcers with topical analgesics.
• Review medication which may be exacerbating the problem.

Drug treatment of sialorrhoea:

• Scopolamine (hyoscine hydrobromide)
  • Comes in various formulations but patch most useful, as avoids first pass liver effect so smaller doses can be used.
  • Put patch behind ear.
  • Lasts 72 hours.
  • Smaller doses can be given by occluding part of patch.  Patches can be cut but this is an unlicensed way of delivering the drug.
  • Side effects include behavioural problems, constipation, cardiac arrhythmia, urinary retention, flushing, nausea, giddiness and confusion, restlessness and blurred vision.
• Glycopyrronium bromide
  • Available as oral/IV/SC formulations
  • Similar effectiveness and side effects to hyoscine
  • Tends to cause less central effects such as confusion
• Botulinum Toxin A
  • Injected into the parotid and submandibular glands
  • Should be done under ultrasound control as injection into other sites may lead to paralysis of critical muscles.
  • Limited data on effectiveness.
  • Only lasts 3-8 months (may get longer effect with repeated injections due to gland hypotrophy).
• Tricyclic antidepressant (TCA)
  • The side effect of these drugs is dry mouth, which is used to treat the sialorrhoea.
  • For a child who might benefit from a TCA for other reasons (e.g. neuropathic pain) this might be an appropriate choice.
• Surgery
  • Three approaches, removing salivary glands, ligating salivary ducts or sectioning nerve supply (denervation procedures reduce taste to anterior 2/3^rd of tongue).
  • Poor success with all types of surgery.
  • Current view is four duct ligation of parotid and submandibular glands.