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copious saliva



First of all I want to thank all of you for responding and carrying on this 
discussion. I also must apologize for responding so slowly.  Main reason for the
slow response is that I had to travel out-of-town to this this client.  
Unfortunately I do not have his chart so that I may not be able to satisfy all 
your questions and will have to go by memory.  

I saw this client for a week as he transferred from the hospital to a nursing 
home. I saw him after Tx had been initated. I saw him Monday in the hospital 
then Tuesday thru Friday and the following Monday & Tuesday in the SNF.  At the 
hospital he ate in his room. There was alot of drooling but he was able to 
control it with reminders.  When he moved to the SNF he ate in the diningroom 
and drooling or his ability to control it decreased. At first he was easily 
distracted and his attending skills decreased in his new environment. As the 
week went on, it began to level off.  The following week he did much better and 
the need for reminders to swallow decreased during meal times and during speech 
sessions. 

1.  With regards to my description of his saliva as varying from thin to ropey: 
    stems from  working previously as a dental hygienist (years ago). Typically 
    we described saliva as thin/serous if it was thin, clear & watery.  Thin
    saliva often had a lower ph or acidic quality and thick ropey saliva often
    had higher ph or alkaline quality and was more cohesive and hung together in
    long strands. Also ropey saliva contained more mucin (protein contained in 
    saliva). 

2.  Yes, to Gerard Brooks, this client is similar to the client you described in
    that there is definately an affective componant. People who have known this
    man for most of his life report he used to be grumpy and non-social.
    He is now social, cooperative and pleasant.  He frequently laughs and
    smiles inappropriately.  He is easily distracted by visual/auditory
    stimuli. Over the 7 days that I worked with him his attention to task &
    hence his response to Tx varied.  He also seems to "hold" saliva in his
    mouth & then it spills over.  Lip seal if fair with greatest weakness in the
    lower left quadrant.  He will respond to reminders to swallow or
    independently swallow for periods of time and then appears to let the saliva
    pool in the anterior 1/3 of his mouth.  He will swallow while holding the   
    saliva anteriorly and mop it up with tissues.  Don't know if it  becomes to
    difficult to continue to swallow frequently so that he takes an easier route
    or if his swallows are inefficient so that with each subsequent swallow   
    residual saliva remains until it builds up to a point where it becomes too 
    much too handle.  

3.  In regards to the palatal training device:  In her book, "Working with
    Swallowing Disorders", Judith Langley, BA, LRAM, MCST, lists this as
    a method for drooling when drooling and hypernasality are present following
    a stroke.  She lists as a resource, Selley WG, "Dental help for the stroke
    patients", British Dental Journal, 143.12, 1977. This man already has an
    upper denture & lower partial.  Don't know how much, if any a remake of his
    upper denture with a palatal extension would increase salivary production. 
    Also don't know if a palatal extension would be appropriate.  Uvula was
    observed at  midline. Nasal emission was noted only during attempts to
    implode air in the oral cavity, nasal air escape noted with a mirror during
    speech. I'm not aware of other tests for nasality which may have been done. 
    He reports that he has snored for many years and can only sleep on his back.

4.  If he continues to have excess saliva that he can't learn to monitor 
    independently than I think the "patch" or similar may be appropriate.
    At this time I don't know what meds he is on.  Other medical Dx's that
    I did not mention previously include: diabetes mellitus & pacemaker (sorry,
    can't remember what others). He mentioned that his vision has been blurry
    since his stroke but has not been seen for an eye exam as yet.

I understand he continues to improve. Again, thank you all for continuing this 
discussion.  My intention is too pass these suggestions to the therapist who is 
now treating this client.  I may or may not have the opportunity to see him 
again.

Dianne Purdy, MAT CCC-SLP   
    








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