Table 2.

Expert panel recommendations for the management of sialorrhea in Parkinson’s disease (PD).

Theme	Specific actions
Earlier diagnosis of sialorrhea	•Raise awareness of sialorrhea among patients with PD, primary and secondary care physicians, and the extensive multidisciplinary team to better engage patients, family members, and caregivers to discuss sialorrhea and properly identify its impact on their lives. Educate all healthcare professionals to better identify sialorrhea symptoms and to make onward referrals as required. Involve caregivers and family members in physician visits to facilitate conversations about sialorrhea. This is particularly important when the patient with PD presents with communication or cognitive difficulties. Use an exhaustive list of non-motor symptoms with patients at every physician visit to ensure that lesser-known symptoms, such as sialorrhea, are not overlooked. Ask specific questions and give examples of possible day-to-day issues to support the conversation around sialorrhea, e.g., do you ever experience any excess saliva in your mouth? Do you ever experience wet lips or drooling of saliva? Do you ever have a wet voice after you eat and drink? Do you feel the need to cough or clear your throat due to excess saliva in your throat? Do you experience stains on your T-shirt? Do you experience a risk of falling due to saliva on the floor? Evaluate the impact of sialorrhea on the patient’s quality of life rather than relying solely on assessments of the volume, frequency, or severity of drooling; some patients may find mild sialorrhea really bothersome, whereas others may not. Consider using a standard rating scale, such as the Drooling Severity and Frequency Scale (DSFS) (Table 3) [27], [28], to quickly assess sialorrhea, identify patients early on, and to monitor changes over time. Table 3. Drooling Severity and Frequency Scale (DSFS) [28]. Drooling Points Severity Dry – never drools Mild – only lips wet Moderate – drool reaches the lips and chin Severe – drool drips off chin and onto clothing Profuse – drooling off the body and onto objects (furniture, books) Frequency No drooling Occasionally drools Frequently drools Constant drooling 1 2 3 4 5 1 2 3 4 The score of the DSFS equals the sum of the severity and frequency sub-scores. Educate healthcare professionals about the importance of a multidisciplinary team approach.
First-line therapy	•Educate patients adequately about sialorrhea and its treatment. Refer patients to a speech and language therapist early in the disease course. Educate clinicians adequately about sialorrhea recognition and treatment with botulinum toxin and increase the number of clinicians who can give botulinum toxin injections.
Cautious use of anticholinergics	•Avoid anticholinergic drugs when possible due to their systemic side effects. If an anticholinergic drug needs to be used, use one that has minimal entry to the central nervous system (CNS), such as glycopyrronium bromide.