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AN ORAL MOTOR PERSPECTIVE ON DROOLING
Drooling, or loss of saliva from the mouth, may occur for a variety of reasons. Gum
or tooth disease, upper respiratory infections, sinus infections, allergies, middle
ear infections, gastroesophageal reflux, medications, mouth breathing, body position,
level of activity, intensity of concentration, and level of alertness may affect
control of secretions and may result in drooling. Abnormal patterns of movement or
muscle weakness for the lips, cheeks, jaw and tongue may also result in drooling.
The focus of this article is drooling due to abnormal patterns of movement or muscle
weakness, both of which may occur in individuals with low muscle tone.
To effectively
and efficiently control oral secretions, the muscles and structures of the oral areas
must constantly make subtle adjustments, twenty four hours a day. The sensory awareness
at the lower cheeks, gums and lips must be present to detect the small changes in
pressure on these tissues, which occur as saliva leaves the salivary ducts and enters
the mouth. Range of cheek movement and lip movement for closure is necessary to maintain
the negative intraoral seal during oral transit for swallowing. Lip power must be
adequate to maintain the lips in a closed position during the swallow. The posterior
cheek muscles must squeeze in toward the teeth and gums to shift the saliva to the
center of the mouth for swallowing. The jaw must elevate to support the midblade
of the tongue as it lifts up to contact the hard palate and propel the saliva into
the pharynx. The soft palate must elevate during the swallow to close the nasal cavity
and to maintain a negative pressure seal within the mouth.
Humans secrete an average
of .5 to 1 Liter of saliva a day and .5 ml per minute during sleep. Due to the quantity
of secretions, and the many coordinated patterns of muscle movement needed to swallow
the saliva consistently, conscious control of secretions is not possible for anyone
during waking hours, and certainly is not possible during sleep. For this reason,
interventions emphasizing conscious control of saliva usually show poor results over
time, and may result in undue frustration for the individual. Medications or surgery
which reduce the amount of saliva produced, without addressing any underlying oral
motor issues, offer partial solutions, but are complicated with potentially serious
side effects. Surgical interventions are considered permanent and irreversible. Before
proceeding with either of these options, a six-month trial of oral motor therapy
is recommended.
To determine the muscle areas involved, a baseline of the components
of muscle movement must be determined. These components include response to pressure
and movement, range of movement, variety of movement, strength of movement, and control
of movement. The areas assessed include the lips, cheeks, jaw, tongue and soft palate.
Observation of the face at rest, and during activities such as eating, drinking,
talking, and during change in facial expression are important. The structures of
the face and mouth should be inspected visually for alignment and symmetry. In addition
to observation, the lips, cheeks, jaw, tongue and soft palate can be manipulated
manually, using the Beckman Oral Motor protocol, to add data regarding the components
of movement listed above. This is especially important if the individual is nonverbal,
on nonoral intake, or cannot follow commands. Findings from this baseline will yield
data critical to the design of an effective intervention program.
The focus of oral
motor intervention will be determined by the baseline assessment. Some examples of
interventions might include increasing sensory awareness at the gums and inner lower
cheeks, increasing passive range of cheek and lip movement, increasing posterior
cheek strength, increasing lip strength at the sides and center of the upper and
lower lips, increasing internal jaw strength, increasing soft palate activation,
and increasing the variety of intrinsic tongue muscle movements. Drooling may still
occur intermittently, especially during the occurrence of teething, gum or tooth
disease, upper respiratory infections, sinus infections, allergies, middle ear infections,
gastroesophageal reflux, mouth breathing, increased level of activity, increased
level of concentration, or decreased level of consciousness. The overall occurrence
of drooling is reduced due to the increased internal oral motor control the individual
has developed. Function is the focus of the treatment outcome.