How to Treat Excess Saliva (Sialorrhea) in ALS

In amyotrophic lateral sclerosis (ALS), the sensation of producing “excess” saliva is actually caused by progressive weakness in the muscles of the mouth and throat used for swallowing ^[1]. This condition, known medically as sialorrhea, occurs because normal amounts of saliva pool in the mouth rather than being swallowed automatically ^[2]. Managing sialorrhea is a top priority in ALS care, as constant drooling can be socially isolating, uncomfortable, and increases the risk of choking or developing aspiration pneumonia—a lung infection caused by inhaling saliva ^[3][4]. Fortunately, there are several effective ways to reduce saliva production and clear the mouth safely ^[5].

Medications to Reduce Saliva

The most common first-step approach is using prescription medications to dry out the mouth. These medications, broadly called anticholinergics, work by blocking the nerve signals that tell the salivary glands to produce saliva ^[6][7].

• Oral and topical medications: Options include pills like glycopyrrolate or amitriptyline, drops like sublingual atropine placed under the tongue, or scopolamine patches worn on the skin ^[8][9].
• Side effects to watch for: Because these medications dry out fluids throughout the entire body, they can cause side effects like constipation, dry eyes, urinary retention, and, in some cases, confusion or cognitive changes ^[6][10].
• Dental health: Saliva naturally protects your teeth. Chronic dry mouth from these medications significantly increases the risk of cavities and oral infections like thrush ^[6]. Maintaining rigorous oral hygiene and regular dental visits is essential while taking them.

Targeted Treatments: Botox and Radiation Therapy

When oral medications are ineffective or cause intolerable side effects, localized treatments can target the salivary glands directly ^[5].

• Botulinum toxin (Botox) injections: A doctor can inject botulinum toxin directly into the salivary glands (often using ultrasound guidance for precision) ^[11][5]. This temporarily blocks the nerve signals to the glands so they produce less saliva ^[12]. The injections are generally safe, highly effective, and typically need to be repeated every few months ^[13][12]. It usually takes a few days to a week to see the full effect.
• Radiation therapy: Administering a low dose of radiation to the salivary glands is another highly effective option when medications fail ^[14]. Radiation therapy can provide a longer duration of symptom relief compared to temporary treatments like Botox, often with very few procedural complications ^[5][15].

Mechanical Clearance and Supportive Care

Reducing saliva production is only half the battle; safely removing pooled saliva is equally important.

• Portable suction machines: A small, quiet suction device (similar to what a dentist uses) can be kept at home to gently vacuum pooled saliva from the mouth ^[1][2]. This helps prevent choking and allows for comfortable breathing and speaking. You typically need a prescription from your doctor to obtain one through a medical equipment supplier so that insurance covers it.
• Cough assist devices: While suction machines clear the upper mouth and throat, a mechanical cough assist device may be needed if secretions drop lower into the airway ^[1].
• Positioning and diet: Working with a speech-language pathologist can help you find head and neck positions that make swallowing easier or allow saliva to drain forward rather than pooling at the back of the throat ^[16][1]. Additionally, avoiding dairy, overly sweet, or acidic foods can help, as these can sometimes stimulate saliva or thicken mucus.

Note: It is crucial to distinguish between thin, watery saliva (sialorrhea) and thick, sticky phlegm. Treatments for thin saliva, like drying medications, can actually make thick phlegm worse. If your secretions become too thick, you may need hydration, natural remedies (like dark papaya or grape juice), or mucolytic medications (such as guaifenesin) instead.