Mouth care and oral management in ALS M. L. Del Bene, MS, RN, NP-P People with ALS often report thickened, mucus-like saliva and/or excessive saliva resulting in drooling. Thickened saliva may be the result of mouth breathing, dehydration, or drooling, where as drooling may be a result of weakened oral muscles that have lost the ability to push the saliva into the back of the mouth to be swallowed. Regardless of the source or specific type of oral challenge experienced, there is help. Improving the symptoms may enhance a person's social experience (controlling the drooling), improve speech production (by removing excessive saliva), as well as decrease the incidence of bacteria or fungal growth (caused by excessive moisture). Some individuals experience dry mouth either in addition to the above or alone. Dry mouth may be related to mouth breathing or dehydration. Mouth breathing occurs when the muscles of the face and mouth are weakened. With of air flowing constantly in and out of the mouth, the amount of water present in the saliva is decreased. Saliva is composed of water and protein. Mouth breathing will evaporate the water present in the saliva but leave the protein element. This results in thickened (viscous) saliva that is difficult to manage and swallow. Dehydration may result from a decreased ability to swallow liquids and also plays a role in thickened saliva. A decrease in the amount of liquid ingested will result in less fluid available for the production of saliva. Additionally, as lip, tongue, and throat muscles become weak, it is increasingly difficult to transport saliva to the back of the mouth. This too may lead to dehydration. Management Thickened saliva may be treated with various interventions: •  Papain is an enzyme that is obtained from the fruit of the papaya plant. The enzyme activity of papain will assist in breaking down the protein element of saliva. Papain is available in health food stores in tablet form and is priced at approximately $7.50 for 250 tablets. Another form of papain is papaya nectar, which is easily ingested if thin liquids are difficult to swallow and will aid in thinning thickened saliva for some individuals. Papaya nectar is a usually available fom general food store. •  Increased fluid intake will help combat the presence of or potential for dehydration. If thin liquids are difficult to swallow, a commercial thickener may be helpful: Thick-it and Nutrathick are two popular brands. Another good option if think liquids are challenging is to increase intake of foods that are high in water content, for example cantaloupe, or watermelon which can be diced, frozen and then whipped to the texture that is best for you. •  Pharmacologic management may include OTC Robitussin to thin out the thick saliva or prescription medications including but not limited to Guaifenisen, or nebulizer treatments with Albuteral Drooling may be treated with the following interventions: •  Pharmacological management with medications that control saliva by drying secretions, such as Robinul, Elavil, Probanthine, and Atropine. Botox injections have also been utilized for excessive saliva though information on its efficacy is limited. •  Mechanical management with a suction machine accompanied by a Yankauer tip, to clear the mouth of excessive, sticky secretions. There are excellent mouth care products that attach to the suction machine tubing to permit better oral care. The Sage company (1-800-323-2220 or www.sageproducts.com) have toothbrush and suction combination tips along with peroxide-mint cleanser to promote better oral hygiene. •  Surgical management by severing the nerve that stimulates the parotid and submandibular glands through the inner ear. This is not always effective and, because of possible complications arising from surgery, this is not the first treatment suggested. Dry Mouth may be treated with the following interventions: •  Increased fluid intake (see above) •  Mechanical management with products that restore the moisture artificially. The Sage company (1-800-323-2220 or www.sageproducts.com) and Biotene company (800-922-5856or www.laclede.com) both manufacture dry mouth care products that are fantastic.