Problems With Tongue Muscles
Parkinsons can also cause problems in the tongue muscles. The tongue is important in swallowing. We use it to move food around and push it to the back of the mouth to trigger the swallowing reflexes. Parkinsons can also impair the reflexes that protect our windpipe from food and drink. A problem coordinating breathing and swallowing may make this problem worse.
Generic Vs Branded Drugs
Currently, there are multiple pharmaceutical companies that manufacture a generic formulation of carbidopa-levodopa, dopamine agonists, monoamine oxidase inhibitors, and anticholinergics. The U.S. Food and Drug Administration requires that generic drugs show a similar risk and benefit to the branded drug prior to market approval, but in rare cases this standard is not high enough.
A review supported by the Parkinsons Foundation reports evidence that if you are in more advanced stages of the disease, switching from branded drugs to generic, or from one generic to another, may have somewhat variable effects. The authors, including Parkinsons Foundation National Medical Advisor Michael S. Okun, MD, believe that the standards for approving generic drugs for PD may not be strict enough to demonstrate that the generic alternatives are equally effective.
Work with your doctor to develop a tailored treatment plan. Using generic drugs will likely provide a cost savings. Infrequently, a person living with PD may require brand medication.
If you make the switch, follow these tips:
- Report to your physician on the effectiveness of the drugs.
- Carefully keep a diary of any side effects.
- Record dose adjustments made by your physicians .
- Try to stay with a single drug manufacturer for your generic medications. You may need to ask your pharmacist to special order for you.
Inflammation Of The Epiglottis
Epiglottitis is inflammation of the epiglottis, tissue that covers the trachea , which helps prevent coughing or choking after swallowing. It is usually caused by the bacteria H. Influenzae but can also be caused by other bacteria or viruses that cause upper respiratory infections.
Top Symptoms: being severely ill, shortness of breath, fever, sore throat, pain with swallowing
Symptoms that never occur with inflammation of the epiglottis: cough
Urgency: Emergency medical service
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How Do You Know If You Or Your Loved One Has A Problem With Swallowing
Swallowing difficulties can start very subtly and initially not be obvious to either the person with PD or their loved ones. There are signs to look out for before swallowing difficulty becomes overt . Some of the signs you should pay attention to include:
- Slow rate of eating people with difficulty swallowing may slow down their eating in order to avoid coughing or choking
- Fatigue during eating or decreased enjoyment of food
- A sensation that food is sticking in the throat
- Coughing or excessive throat clearing during eating
- Difficulty in swallowing pills
- Unexplained weight loss people with difficulty swallowing may reduce their consumption in an attempt to eat without coughing or choking
- Change in dietary habits people with difficult swallowing may alter their diet in order to avoid foods that cause difficulty. This may not be a choice made consciously
- Diagnosis of a pneumonia this could be caused by aspiration, or entry of a foreign substance into the airway
If you think there might be a swallowing issue, it is important to speak with your doctor about it. There are steps you can take to properly assess the situation and improve your swallowing function. This can in turn reduce your risk of choking, make eating more enjoyable, and lessen the chances of unwanted weight loss and/or other discomforts.
Swallowing Exercises Can Be Very Helpful To Improve Your Swallowing
After a formal swallow assessment, swallowing therapy sessions can be designed for you, involving exercises tailored to the specific parts of your mouth and throat that are causing the swallowing problem. Sessions may involve practicing compensatory swallowing strategies with various types of foods in order to maximize safety and efficiency while swallowing.
During swallow therapy, recommendations may include:
- Best feeding techniques
- Exercises to strengthen oral and throat muscles
- Compensatory techniques to assist in safe swallowing
- Oral and mouth care techniques
- Appropriate food selection and ways to modify food texture
- Safe positioning strategies
- Patient/family education
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Why Does Parkinsons Disease Cause Drooling
Saliva is produced by small glands around our mouth, called Salivary glands.
It is a common misconception that Parkinsons patients have drooling because they are producing too much saliva. In fact, multiple studies have shown that most Parkinsons patients produce less saliva.
Our salivary glands continuously produce saliva, even when we are not eating.
Normally, we automatically swallow this saliva, through small gulps that we dont even notice.
But in Parkinsons disease, there is a marked decrease in all automatic movements, including automatic swallowing.
Therefore, saliva accumulates in the mouth. When the mouth is full, it drips out. We call this Drooling.
Lets talk about treatment
Mechanisms For Drooling Disturbance In Pd
Patient reports of too much saliva in my mouth suggest hypersalivation as a cause. However, saliva production appears unchanged or even depressed in PD, indicating excessive salivation is not a crucial factor.26,3840,4547
Decreased salivary flow may relate to dysautonomia in PD. Hyposecretion may arise from medications common in PD.20,21,36 Altered reaction to stimulation, from reduced olfactory and other sensory triggers, may also play a role.48 Hou et al49 conducted a fMRI investigation to examine basal ganglia functional connectivity in drug-naïve people with PD who did or did not drool. Those with sialorrhea showed significantly reduced functional connectivity of putamen within bilateral sensorimotor cortices, superior and inferior parietal lobules and areas in the right occipital and temporal lobes.
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Pathophysiology Of Drooling In Pd
In addition, a recent study showed that severe hypomimia, unintentional mouth opening and stooped posture with dropped head, could cause drooling in PD patients by losing the ability to maintain saliva within the oral cavity . In contrast, there is no obvious evidence that medication-induced dyskinesia can produce drooling. The possible domains contributing to the pathophysiology of drooling in PD are summarized in Figure 1.
Possible pathophysiology of drooling in Parkinson’s disease
Managing Eating And Swallowing
It is important to continue eating normally as long as it is safe to do so. This will help to keep your muscles working, and maintaining a healthy diet is vital to good health . Only when eating and swallowing become significantly uncomfortable or difficult should you adapt your diet, for example by eating pureed foods.
Swallowing difficulties are individual and solutions vary from person to person, but the following tips on diet, drinking and eating techniques may help.
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What Research Is Being Done
The National Institute of Neurological Disorders and Stroke , a component of the National Institutes of Health, is the primary funder of research on the brain and nervous system. NIH is the leading funder of biomedical research in the world.
PSP is one of the diseases being studied as part of the NINDS Parkinsons Disease Biomarkers Program. This major NINDS initiative is aimed at discovering ways to identify individuals at risk for developing Parkinsons disease and related disorders, and to track the progression of these diseases. NINDS also supports clinical research studies to develop brain imaging that may allow for earlier and more accurate diagnosis of PSP.
Genetic studies of PSP may identify underlying genetic causes. Previous studies have linked regions of chromosomes containing multiple genes, including the gene for the tau protein , with PSP. Researchers hope to identify specific disease-causing mutation and are also studying how genetics and environment interaction may work together to contribute to disease susceptibility.
Animal models of PSP and other tau-related disorders, including fruit fly and zebrafish models, may identify basic disease mechanisms and lead to preclinical testing of potential drugs. Other studies in animal models focus on brain circuits affected by PSP, such as those involved in motor control and sleep, which may also yield insights into disease mechanisms and treatments.
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A Exercises To Improve Swallowing Difficulty :
A speech-swallow therapist evaluates how your muscles move while swallowing. They can teach you important exercises to improve swallowing difficulty and prevent Aspiration.
Speech therapists specially trained in Parkinsons can teach you exercises such as Expiratory Muscle Strength Training or Lee Silverman Speech Therapy or LOUD therapy.
These specialized training sessions are tremendously helpful in improving voice. But these exercises also make swallowing easier.
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Normal Physiology Of Salivation And Swallowing
The processes of salivation are controlled by both sympathetic and parasympathetic nervous system. However, facilitation of ingestion and swallowing are mainly contributed by parasympathetic nervous system. The parasympathetic afferent pathways receive unconditioned reflex stimulation from the pharynx and esophagus. Then, signals are conducted via the vagus and spinal splanchnic nerves to the salivary center located in the medulla. The parasympathetic outputs are conducted via two different pathways including the glossopharyngeal nerve, which then innervates the otic ganglion, and, subsequently, to the parotid glands via the auriculotemporal nerve and the facial nerve through the chorda tympani nerve to the submandibular ganglia and then innervates the submandibular and sublingual glands via the lingual nerve .
Objective Measures Of Flow/volume
Objective measurements of milliliters or milligrams secretion per minute typically center around gathering saliva at regular intervals over given time periods.68,69 Sampling methods include collecting saliva from cups placed over salivary ducts, expectoration into pots or tubes, weighing of gauze or cotton rolls held at given loci in the mouth, use of centrifuges to extract saliva from the gauze to quantify the volume of saliva absorbed or allowing saliva to dribble from the mouth with the head held forwards over receptacles.
As secretion is sensitive to a number of influences, gathering ideally occurs under controlled conditions. Posture is controlled the environment is quiet, with absence or minimization of visual, olfactory or gustatory stimuli known to prompt increased flow. Comparability of stimulated flow across patients and time demands use of standard stimulatory material and doses . To assure inter- and intra-individual comparability, evaluations ideally happen at the same time of day at the same point in the drug cycle in the same relationship to meal times . Onoff status and fluctuations need to be monitored as well as presence and severity of dyskinesias that may affect measurements.70
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Eating Swallowing And Saliva Control
Some people with Parkinsons may find they have problems with eating, swallowing and controlling their saliva.
This information looks at the issues you may face, explains why they happen and what help is available.
Eating is a social activity and problems that affect chewing and swallowing can have a big impact on how much you enjoy meal times. For example, some people with Parkinsons have told us that they feel self-conscious or embarrassed while eating because of their symptoms.
Its important to look out for symptoms related to difficulties with eating and swallowing. These can develop slowly over time and you may not notice them, so family, friends or carers should know what to look out for too.
If youre not able to swallow properly, you may experience:
- discomfort in the chest or throat
These things can lead to a number of long-term problems, including:
Talk to your GP as soon as you can if you have problems with eating or swallowing they may refer you to specialists who can help.
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Treatment Options For Drooling In Pd
First, treatment should begin by withdrawing medications that aggravate drooling such as cholinesterase inhibitors, clozapine or quetiapine. Next, the target might be to improve motor symptoms by using dopaminergic medications or by performing deep brain stimulation if the motor symptoms otherwise justify these approaches. However, the response of drooling is usually only partial and there is clearly a need for a specific adjunctive treatment for this problem. Specific treatment options for drooling in PD are both pharmacological and nonpharmacological.
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Excessive Drooling A Sign Of Greater Dysfunction In Parkinsons Disease
Excessive drooling by patients with advanced Parkinsons disease is an indicator of greater motor and nonmotor dysfunction, new research shows.
Sialorrhea is not just a cosmetic problem, study investigator Francesca Morgante, MD, associate professor of neurology, St. Georges University, London, United Kingdom, told Medscape Medical News.
We need to understand the relationship between sialorrhea and these speech and swallowing disturbances and whether treatment for sialorrhea improves that, Morgante added.
The findings were presented at the virtual Congress of the European Academy of Neurology 2021.
Data Collection And Analysis
Selection of studies
We will merge search results using reference management software, remove duplicate records of the same report, and import the results into Covidence, a webbased systematic review software platform . In Covidence two review authors will independently examine titles, abstracts and key words identified from the literature search. The results of this search will be categorised as either yes, no, or maybe relevant. If it is unclear from titles and abstracts whether a study should be included, we will obtain full texts of these trial reports for further examination. We will resolve disagreement about selection of studies by consensus discussion. We will list those studies excluded in the Characteristics of excluded studies table. FH will retrieve full texts of relevant and potentially relevant reports and link multiple reports of the same study. Two authors will independently examine the full texts for compliance with eligibility criteria. We will contact study authors for further information, where appropriate, to clarify study eligibility. The review team will not be blinded to information about study authors, institutions, journal of publication, or results. We will resolve any disagreements through discussion.
Data extraction and management
Assessment of risk of bias in included studies
Measures of treatment effect
0% to 40%: might not be important.
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Description Of The Condition
Parkinsons disease is a progressive degenerative disorder of the nervous system that results from death of dopaminegenerating cells in the basal ganglia in the brain . Motor symptoms affecting movement are the cardinal features of PD, but are typically accompanied by a range of nonmotor symptoms that may include disturbances in speech, cognition, and mood, and may affect swallowing, sleep, and autonomic body functions such as regulation of blood pressure and temperature, and saliva control .
Drooling, which generally refers to an involuntary loss of saliva , is a common problem for people with PD. Drooling in the literature is also frequently termed dribbling, hypersalivation, ptyalism, and sialorrhoea . Anterior drooling, which describes visible loss of saliva from the mouth, is distinct from posterior drooling where saliva spills into the pharynx .
What Is The Prognosis
The disease gets progressively worse, with people becoming severely disabled within three to five years of onset. Affected individuals are predisposed to serious complications such as pneumonia, choking, head injury, and fractures. The most common cause of death is pneumonia. With good attention to medical and nutritional needs, it is possible for individuals with PSP to live a decade or more after the first symptoms of the disease appear.
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Assessment Tools For Drooling In Pd
The assessment tools to evaluate drooling in PD include both objective and subjective measures. Objective tools were developed to measure the volume of saliva and salivary flow. The limitations of these tools are that they are time-consuming and cannot evaluate the psychosocial impairment. Therefore, subjective tools were developed. The subjective measures in many previous studies were the UPDRS part II salivary subscores to evaluate drooling treatment responses and visual analog scales to assess the frequency, familial and social distress however, not all scales are validated. Three drooling-specific rating scales including the Drooling Severity and Frequency Scale , Drooling Rating Scale and Sialorrhea Clinical Scale for PD have been used to evaluate drooling in PD. The DSFS, a semi-quantitative scale, was used in studies to evaluate drooling in PD and cerebral palsy . The scale is composed of two domains: the severity of drooling rated on a five-point scale and frequency of drooling rated on a four-point scale. Since the DSFS is easy to administer it is widely used. However, the limitations of this scale are no assessment of the psychosocial impact, no validation and no evidence of correlation between this scale and the objective measures of salivary secretion.
Choosing Foods For Successful Eating
Part of formal swallow therapy will be to make appropriate food suggestions that you can eat safely. Good food choices include:
- Foods that dont require vigorous chewing. Avoid dry and crumbly foods.
- Moderately textured wheat breads instead of very coarse, nutty breads or very soft, white breads.
- Oatmeal, cream of wheat or moistened dry cereals instead of coarse, dry cereals.
- Well-cooked, tender chicken/turkey, well-cooked fish without bones, chopped and ground meats, instead of stringy, tough meats that require a lot of chewing.
- Soft casseroles and poached or scrambled eggs
- Mashed potatoes or rice, moistened with gravy or margarine, instead of wild rice or French-fried potatoes.
- Soft, cooked pasta elbows, instead of long spaghetti.
- Soft, well-cooked vegetables, cut up or creamed, instead of raw vegetables or those with a hard texture.
- Pureed or mashed fruits, fruit juices and fruit sauces, instead of fruits with seeds or hard outer skins. Avoid nuts, seeds or coconut.
- Custard, yogurt, ice cream or other soft desserts
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Drooling In Parkinsons Disease: A Multifactorial Symptom
1Neuromuscular Rehabilitation Research Center, Semnan University of Medical Sciences, Semnan, Iran
2Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
3School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
How to Cite:BakhtiyariJ, MehriA, MaroufizadehS, AmanianH. Drooling in Parkinsonâs Disease: A Multifactorial Symptom,Arch Neurosci.2020 7:e99300. doi: 10.5812/ans.99300.
Archives of Neuroscience:Article Type: