Saliva Management
Manage drooling, thick saliva and secretions
Review status: Waiting for team review. An AI editorial check was completed on 2026-08-14 by claude-opus-5. It checks clarity, attribution and scope against the sources, and it is not a Compass team or clinical sign-off. Waiting for clinical review. Last updated 2026-08-14.
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Planning 3
- Notice and describe the problemNote whether saliva is too much or too thick, when it is worst, and how it affects eating, talking or sleep.Why it matters: A clear description helps your team find the cause and the right treatment faster.
- Raise it with your team earlyTell your GP or MND team, since saliva problems are common, manageable, and worth not putting up with.Why it matters: Saliva changes can affect comfort and breathing, so early help makes a real difference.
- Work through the options togetherExplore what helps with too much or too thick saliva, and how it connects to swallowing and breathing care.Why it matters: There are several options, and the best one depends on your situation, so it is worth reviewing together.
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Saliva problems are common in ALS/MND, and they come in two opposite forms. They can be uncomfortable and affect confidence, but there are recognised ways to manage them. They are well worth raising, even though they can feel awkward to talk about.
Too much saliva, or drooling (sialorrhoea). This is rarely because the body is making more saliva. Usually it is because swallowing has weakened, so the normal saliva you always made is not cleared away as easily and pools in the mouth. It can then spill as drooling, or feel like it is "too much". Difficulty keeping the lips closed, or holding the head up, can add to it.
Thick or sticky saliva. Some people have the opposite problem. Saliva can be thick, stringy or hard to shift, and it can sit at the back of the throat and be difficult to clear. This can be made worse by dehydration, or by some medicines (including, sometimes, treatments used for too much saliva). Breathing through your mouth can also leave the mouth dry and uncomfortable.
These two problems are managed in different ways, and getting the balance right matters. Drying up thin saliva can make any thick saliva worse. That is why it is handled by your care team rather than by guesswork.
Saliva problems can affect comfort, speech, sleep, eating and dignity, so they are worth taking seriously. The good news is there is a real range of things that can help, covered in the other questions on this card. The key message is simply: it is common, it is not something to put up with, and it is worth raising with your team.
Explained: what this word meansEvidence for this answer
The sources the Compass team used to write this answer. Highlighted phrases in the answer above correspond to the statements below.
Statement 1 of 3. Drooling in ALS/MND usually comes from weakened swallowing leaving normal saliva to pool, rather than from making more saliva.
Supports this. Saliva management in MND — MND Australia · Organisation · June 2021
States the mechanism directly: drooling is not caused by producing more saliva, but by losing the ability to manage the normal amount as the tongue, lip and swallowing muscles weaken.
“Sialorrhoea or drooling does not occur due to excess saliva production but rather a decreased ability to manage normal saliva production due to weakness of the tongue, lip and swallowing muscles.”
ManagementLink checked August 2026
Statement 2 of 3. There is a recognised set of ways to manage saliva problems in ALS/MND, although how well they work varies.
Qualifies this. Saliva management in MND — MND Australia · Organisation · June 2021
Agrees that saliva should be actively managed, but is cautious about results. It calls excess saliva one of the hardest symptoms in MND to address, so having recognised options is not the same as reliable relief.
“Management of excess saliva in people living with MND is one of the most difficult symptoms to address.”
Saliva managementLink checked August 2026
Supports this. NICE MND guideline — NICE · Clinical guideline
NICE NG42 sets out a recognised sequence of things to offer for drooling, beginning with practical advice, so there is a defined set of measures to try. It does not say how often they work.
“If a person with MND has problems with drooling of saliva (sialorrhoea), provide advice on swallowing, diet, posture, positioning, oral care and suctioning.”
1.8.11Link checked August 2026
Statement 3 of 3. Treatments that dry up thin saliva can make thick saliva worse.
Adds context. NICE MND guideline — NICE · Clinical guideline
NICE NG42 does not state the link outright. What it does is treat it as routine practice: recommendation 1.8.15 says that when someone has thick, tenacious saliva the first step is to review all their current medicines, and especially any treatment they are having for drooling.
Link checked August 2026
Used across the whole answer
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There is a good range of options for too much saliva or drooling, from simple measures to medical treatments. The right choice depends on you, and it is decided with your care team. It helps to know what exists so you can have the conversation.
Simple, practical measures:
- Positioning. Sitting more upright and supporting the head can reduce pooling and spilling.
- Swallowing reminders and technique. A speech pathologist can suggest ways to clear saliva more effectively.
- Suction. A small, quiet suction device can clear saliva from the mouth when needed, which some people find very helpful.
- Practical aids. For comfort and dignity, such as discreet ways to manage drooling.
Medical treatments that a clinician may consider:
- Medicines that reduce saliva (a group often called anticholinergics), which can come as tablets, drops, patches or other forms. They have side effects that need weighing up against the benefit, and they differ in how much they affect the brain and nervous system, which is why guidelines suggest one with fewer of those effects for people who have changes in thinking or memory.
- Botulinum toxin injections into the saliva glands, which are used to reduce saliva for a time. The trial evidence in ALS/MND is limited: one small study found that botulinum toxin type B probably reduced the measured amount of saliva at eight weeks, and the evidence on type A was too uncertain for any conclusion.
- Occasionally, other treatments such as radiotherapy to the saliva glands, in specific situations.
An important balance: drying treatments can make saliva thicker, which can create the opposite problem (covered in the next question). So your team will aim for the right balance for you and may adjust over time. These are all clinician-led. The specific choice, and any medicine or dose, is for your team to decide and monitor.
The main thing to take away is that there are recognised treatments for drooling and you do not have to put up with it. If it is bothering you, raise it. Your team can work through the options and find what helps.
Explained: what this word meansEvidence for this answer
The sources the Compass team used to write this answer. Highlighted phrases in the answer above correspond to the statements below.
Statement 1 of 5. Medicines used to reduce saliva have side effects that have to be weighed against the benefit, and they differ in how much they affect the central nervous system, which is why NICE NG42 suggests a medicine with fewer such effects for people with cognitive impairment.
Qualifies this. Saliva management in MND — MND Australia · Organisation · June 2021
Says the drugs used for saliva may be only partly beneficial and that their side effects have to be considered, with treatment tailored to how much the symptom affects the person and balanced against those side effects.
“Currently, there are a number of drugs that may be, at least partially, beneficial, but side effects need to be considered.”
Pharmacological management:Link checked August 2026
Adds context. NICE MND guideline — NICE · Clinical guideline
Shows that the medicines in this group are not interchangeable on side effects. NICE NG42 has a separate recommendation for people with cognitive impairment precisely because one option has fewer central nervous system side effects. It does not list the side effects themselves.
“Consider glycopyrronium bromide as a first-line treatment for sialorrhoea in people with MND who have cognitive impairment, because it has fewer central nervous system side effects.”
1.8.13Link checked August 2026
Statement 2 of 5. One small trial found that botulinum toxin type B probably reduced measured saliva production at eight weeks in ALS/MND. The evidence on botulinum toxin type A was too uncertain to draw conclusions.
Adds context. NICE MND guideline — NICE · Clinical guideline
Shows where this option sits in UK practice: NICE NG42 recommends referral to a specialist service for botulinum toxin A, as either a first or a second treatment to try. That is a practice recommendation, not a trial result, and type A is not the type the trial evidence above covers.
“Consider referral to a specialist service for botulinum toxin A for first- or second-line treatment.”
1.8.14Link checked August 2026
Statement 3 of 5. Radiotherapy to the saliva glands is one of the less common treatments used for drooling.
Supports this. Saliva management in MND — MND Australia · Organisation · June 2021
Lists low dose, one sided radiotherapy to the saliva glands among the treatments used for drooling in MND, alongside anticholinergic medicines, amitriptyline and botulinum toxin injections.
“Sialorrhoea treatments include suction, drug treatments and more invasive approaches, such as injection of botulinum toxin or irradiating the salivary glands, which may improve sialorrhoea and QoL.”
Pharmacological management:Link checked August 2026
Statement 4 of 5. Treatments that dry up saliva can make saliva thicker.
Adds context. NICE MND guideline — NICE · Clinical guideline
NICE NG42 does not state the link outright. What it does is act on it: recommendation 1.8.15 says that when someone has thick, tenacious saliva the first step is to review all their current medicines, and especially any treatment they are having for drooling.
Link checked August 2026
Statement 5 of 5. There are recognised treatments for drooling in ALS/MND, so it does not have to be put up with in silence.
Qualifies this. Saliva management in MND — MND Australia · Organisation · June 2021
Agrees that saliva should be actively treated, but is more cautious about how well it works. It calls excess saliva one of the hardest symptoms in MND to address, and says the medicines used rest largely on good clinical practice rather than trials, so having recognised treatments is not the same as reliable relief.
“There are few randomised controlled trials to confirm the efficacy of drugs and interventions to manage this disabling and troubling symptom.”
Pharmacological management:Link checked August 2026
Used across the whole answer
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Thick, sticky saliva that is hard to clear is a different problem from drooling, and it needs a different approach. The aim is usually to thin the saliva and make it easier to move.
Things that often help:
- Staying well hydrated. Thick saliva is often worse when you are a little dehydrated, so regular fluids can make a real difference.
- Humidifying the air, especially at night or if you use breathing support, which can stop saliva drying out.
- Reducing mouth breathing where possible, and good mouth care to keep things comfortable.
- Reviewing medicines. This is important: medicines used to dry up excess saliva can make any thick saliva worse. If you are on one and your saliva has become thick, that is worth raising. Your team can rebalance things. (Do not stop a prescribed medicine on your own; ask your team.)
- Clearance support. If thick saliva is collecting and hard to cough up, techniques and devices that help clear secretions can be useful. These are covered on the cough assist card and guided by a physiotherapist or respiratory team.
Some people also try gentle measures like sips of certain drinks; a speech pathologist or dietitian can suggest what is safe given any swallowing changes.
As with excess saliva, the balance matters. Because it interacts with medicines and with swallowing and breathing, it is best worked through with your team rather than alone. If thick saliva is bothering you, it is very worth mentioning, because small adjustments often bring real relief.
Explained: what this word meansEvidence for this answer
The sources the Compass team used to write this answer. Highlighted phrases in the answer above correspond to the statements below.
Statement 1 of 3. Keeping fluids up is part of the standard management of thick, sticky saliva.
Supports this. NICE MND guideline — NICE · Clinical guideline
NICE NG42's recommendation for thick, tenacious saliva (1.8.15) includes giving advice on hydration, alongside swallowing, diet, posture, positioning, oral care and suctioning.
Link checked August 2026
Supports this. Saliva management in MND — MND Australia · Organisation · June 2021
Puts checking fluid intake first among the non drug measures it lists for thick, tenacious saliva in MND.
Link checked August 2026
Statement 2 of 3. Humidification is one of the treatments recommended for thick, sticky saliva.
Supports this. NICE MND guideline — NICE · Clinical guideline
NICE NG42 recommendation 1.8.15 says to consider treatment with humidification for thick, tenacious saliva, along with nebulisers and carbocisteine.
Link checked August 2026
Statement 3 of 3. Medicines given to reduce excess saliva can make thick saliva worse.
Adds context. NICE MND guideline — NICE · Clinical guideline
NICE NG42 does not state the link outright. What it does is act on it: recommendation 1.8.15 opens by telling clinicians that someone with thick, tenacious saliva should have all their current medicines reviewed, and especially any treatment they are having for drooling.
Link checked August 2026
Used across the whole answer
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Saliva, swallowing and breathing are closely connected, which is why saliva is managed alongside them rather than on its own.
- Saliva and swallowing. Most saliva problems start with swallowing. When swallowing weakens, saliva is not cleared as easily, so it pools (drooling) or sits at the back of the throat. This is why a speech pathologist is often involved, and why managing swallowing and saliva goes together. (Swallowing has its own card.)
- Saliva and breathing. Saliva that is not cleared can sometimes go towards the airway instead of being swallowed. This is a form of aspiration. Thick saliva can also be hard to cough up if the cough has weakened. This is why saliva links with the respiratory side of care, including cough support (covered on the cough assist card). If you develop signs of a chest infection, see a doctor as soon as possible rather than waiting for your next appointment.
Because of these connections, getting saliva right can have knock-on benefits. These can include more comfort and better sleep. And the reverse is true too: the team will think about how a saliva treatment might affect swallowing or breathing, and aim for the right overall balance.
The practical takeaway is that saliva is not a small or separate issue. It sits within your wider care, and the people who help with your swallowing and breathing are usually the ones who help with saliva too. If saliva is a problem, mentioning it lets your team look at the whole picture and find what helps most.
Explained: what this word meansEvidence for this answer
The sources the Compass team used to write this answer. Highlighted phrases in the answer above correspond to the statements below.
Statement 1 of 2. When swallowing weakens, saliva is no longer cleared and pools in the mouth or at the back of the throat.
Supports this. Saliva management in MND — MND Australia · Organisation · June 2021
States the mechanism directly: drooling is not caused by producing more saliva, but by losing the ability to manage the normal amount as the tongue, lip and swallowing muscles weaken.
“Sialorrhoea or drooling does not occur due to excess saliva production but rather a decreased ability to manage normal saliva production due to weakness of the tongue, lip and swallowing muscles.”
ManagementLink checked August 2026
Statement 2 of 2. Saliva that is not cleared can go towards the airway rather than being swallowed.
Supports this. Saliva management in MND — MND Australia · Organisation · June 2021
Says a build up of saliva raises the risk of choking, and the review of sialorrhoea it reproduces further down the same page describes saliva held in the mouth leading to aspiration and then to pneumonia.
“A build up of saliva and thick tenacious mucus can disrupt sleep and increase the risk of choking.”
ManagementLink checked August 2026
Adds context. NICE MND guideline — NICE · Clinical guideline
Shows that saliva is treated as a breathing matter and not only a swallowing one: when someone has saliva problems, NICE NG42 says to assess their respiratory function alongside the saliva itself.
“If a person with MND has problems with saliva, assess the volume and viscosity of the saliva and the person's respiratory function, swallowing, diet, posture and oral care.”
1.8.10Link checked August 2026
Used across the whole answer
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The simple answer is: as soon as it bothers you. Saliva problems can feel awkward or trivial to bring up, but they are common, your team will have helped many people with them, and there is usually something worth trying. You do not need to wait until it is severe.
It is worth raising if you notice:
- drooling, or saliva pooling and being hard to manage
- thick or sticky saliva that is hard to clear
- saliva affecting your speech, sleep, eating, or confidence
- coughing on saliva, or saliva seeming to "go down the wrong way"
- saliva problems after starting a new medicine (including one for saliva itself)
If you are often coughing on saliva, mention it sooner than the rest, since saliva and the airway are connected.
Signs of a chest infection are different, and should not wait for your next contact. If you develop a fever, more phlegm, a cough that has changed, or you feel more breathless, see a doctor as soon as possible. A chest infection is one of the reversible causes of worsening breathing that guidelines tell teams to treat first, and saliva that is not cleared can be breathed in and lead to pneumonia. If breathlessness comes on suddenly, or is getting rapidly worse, seek medical attention immediately by calling emergency services or going to an emergency department.
You can raise it with whoever you see, such as your neurologist, MND/ALS nurse, GP, speech pathologist or palliative care team. Saliva is often handled across the team, so any of them can start the conversation or point you to the right person.
The thing to hold onto is that this is a recognised, manageable part of ALS/MND. It is not something to feel embarrassed about or to endure quietly. Bringing it up early gives the most options and the quickest relief. The next question lists some things you might ask.
Explained: what this word meansEvidence for this answer
The sources the Compass team used to write this answer. Highlighted phrases in the answer above correspond to the statements below.
Statement 1 of 4. Saliva and the airway are connected, so coughing on saliva involves breathing as well as swallowing.
Supports this. NICE MND guideline — NICE · Clinical guideline
Treats saliva as a breathing matter as well as a swallowing one: when someone with MND has saliva problems, NICE NG42 says to assess their respiratory function alongside the saliva itself.
“If a person with MND has problems with saliva, assess the volume and viscosity of the saliva and the person's respiratory function, swallowing, diet, posture and oral care.”
1.8.10Link checked August 2026
Supports this. Saliva management in MND — MND Australia · Organisation · June 2021
Says a build up of saliva and thick mucus raises the risk of choking, and the review of sialorrhoea it reproduces further down the same page describes saliva held in the mouth leading to aspiration and then to pneumonia.
“A build up of saliva and thick tenacious mucus can disrupt sleep and increase the risk of choking.”
ManagementLink checked August 2026
Statement 2 of 4. A chest infection is one of the reversible causes of worsening breathing in MND, and NICE NG42 tells teams to treat those causes before considering other treatments.
Supports this. NICE MND guideline — NICE · Clinical guideline
Names respiratory tract infections as a reversible cause of worsening breathing in MND, and puts treating them ahead of anything else, so a chest infection is dealt with as a breathing problem in its own right rather than as part of the disease taking its course.
“Treat people with MND and worsening respiratory impairment for reversible causes (for example, respiratory tract infections or secretion problems) before considering other treatments.”
1.13.1Link checked August 2026
Statement 3 of 4. Saliva that is not cleared from the mouth can be breathed in, and that aspiration can lead to pneumonia.
Supports this. Saliva management in MND — MND Australia · Organisation · June 2021
The review of sialorrhoea reproduced on this page lists the serious complications of saliva held in the mouth in ALS: choking, and aspiration followed by pneumonia.
“Moreover, the excess mouth-retained saliva in ALS patients may lead to serious complications, such as choking, which causes anxiety, and aspiration with the consequent pneumonia.”
Pharmacological management:Link checked August 2026
Statement 4 of 4. A change in saliva after starting a new medicine, including a medicine for saliva, is worth raising.
Adds context. NICE MND guideline — NICE · Clinical guideline
NICE NG42 does not tell the reader when to raise it, but it does tell clinicians where to look: recommendation 1.8.15 says that someone with thick, tenacious saliva should have all their current medicines reviewed, and especially any treatment they are having for drooling.
Link checked August 2026
Used across the whole answer
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Saliva problems are common, and there are recognised ways to manage them, so a few questions can help you get the right support. Pick whichever fit your situation.
Understanding it
- Is my problem too much saliva, thick saliva, or both, and what is driving it?
- How does this connect with my swallowing and breathing?
Options
- What can help, from simple measures to medicines or other treatments?
- What are the benefits and downsides of the options for me?
- If a medicine is suggested, what are the side effects, and could it make my saliva too thick (or too thin)?
Practical
- Would a suction device or positioning help, and can we arrange them?
- Could a speech pathologist help with swallowing and saliva together?
Keeping it balanced
- How will we know if the treatment is working, and can it be adjusted?
- Who do I contact if it changes or a new problem appears?
It is completely fine to raise this even though it can feel awkward. It is a common, recognised issue, and your team would far rather help than have you put up with it. The aim is comfort and dignity, balanced safely with your swallowing and breathing.
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