Journal of

Oral Pathology & Medicine

J Oral Pathol Med (2011) 40: 582–586
ª 2011 John Wiley & Sons A/S Æ All rights reserved doi: 10.1111/j.1600-0714.2011.01027.x

wileyonlinelibrary.com/journal/jop

Salivary osmolality and hydration status in children with

cerebral palsy
Maria Teresa B. Santos1, Renato Batista2, Renata O. Guaré2, Mariana F. Leite2,
Maria Cristina D. Ferreira3, Marcelino S. Durão4, Oliver A. Nascimento5, Jose R. Jardim6
1
Individuals with Special Needs Division, Universidade Cruzeiro do Sul, Director Dentistry Division Lar Escola São Francisco São
Paulo, Brazil; 2Centro de Cieˆncias Biológicas e da Saúde, Universidade Cruzeiro do Sul, São Paulo, Brazil; 3Universidade Paulista,
São Paulo, Brazil; 4Nephrology Division, Universidade Federal de São Paulo, Brazil; 5Universidade Federal de São, Brazil;
6
Respiratory Diseases, Universidade Federal de São, Brazil

BACKGROUND: Unstimulated whole salivary parame- by saliva, the earlier this condition is identified the
ters have been identified as potential markers of hydra- greater the chances of administering preventive mea-
tion status. Reduced salivary flow rate and increased sures. Moreover, salivary osmolality is a reliable param-
salivary osmolality have been shown to be useful to eter that reflects changes in plasma and urine.
identify dehydration, even when minimal loss of body J Oral Pathol Med (2011) 40: 582–586
water occurs. This study aimed to evaluate whether
unstimulated salivary flow rate and salivary osmolality Keywords: cerebral palsy; plasma osmolality; salivary flow rate;
from individuals with cerebral palsy correlate with plas- salivary osmolality; urine osmolality
ma and urine osmolality.
METHODS: Thirty-five male and female children, aged
9–13 years old, diagnosed with cerebral palsy were com-
pared to 27 nondisabled children (10–12 years old). Introduction
Unstimulated whole saliva was collected under slight
suction and salivary flow rate (ml ⁄ min) was calculated. Cerebral palsy (CP) describes a group of chronic
Plasma without venostasis and urine were also collected. disorders that involves movement and posture develop-
Salivary, plasma and urine osmolality were measured ment, often accompanied by epilepsy, secondary mus-
using a freezing point depression osmometer. culoskeletal problems and disturbances of sensation,
RESULTS: Cerebral palsy children presented a reduction perception, cognition, communication and behavior (1).
in salivary flow rate (50%) compared to the control group It is the most common cause of severe physical disability
(P < 0.01). Moreover, an increase in salivary (50%), plas- in childhood (2), with an estimated prevalence of 2.4 per
ma (3%), and urine osmolality (20%) was also observed in 1000 children (3).
the cerebral palsy children compared to the control Previous studies in CP individuals have demonstrated
group (P < 0.01). Salivary flow rate was negatively cor- a reduced salivary flow rate (4), decreased sodium
related with the salivary, plasma and urine osmolality concentrations, increased potassium levels (5), reduction
(P < 0.01). Salivary osmolality correlated positively with in digestive and antimicrobial enzymes activities, such as
plasma and urine osmolality (P < 0.01). amylase and peroxidase, respectively (6), increased sialic
CONCLUSION: Cerebral palsy children seem to present acid concentrations that could be related to increased
impaired adequate hydration status. Since the possible saliva viscosity (6) and delayed recovery of salivary
hypohydration condition may be reflected in saliva fluid, pH, involving compromised ability to buffer exogenous
which could compromise the protective function exerted acid (7).
Water is essential for several physiological processes,
including biochemical reactions, metabolism, substrate
for transport across cellular membranes, temperature
regulation, and circulatory function. Body turnover of
fluid and electrolytes changes constantly due to water
Correspondence: Maria Teresa B Santos, DDS, PhD, Individuals loss from the lungs, skin and kidney and water gain
with Special Needs Division, Universidade Cruzeirio do Sul; Director from food and fluids (8). Several methods have been
Dentistry Division Lar Escola São Francisco, Rua Constantino de
Souza, 454, apto 141, 04605-001 São Paulo, SP, Brazil. Tel:+55 11
used as markers of hydration status, including stable
9972 2301, Fax:+55 11 5093 0865, E-mail: [email protected] isotope dilution, bioelectrical impedance spectroscopy,
Accepted for publication January 26, 2011 body mass change (9), hematological and urinary
 Saliva and hydration status in cerebral palsied
Santos et al.

583
parameters (10). The ideal selection of hydration Saliva collection
markers should be based on a compromise between Unstimulated whole saliva was collected using slight
their capacity to identify hydration status with simple suction through a soft plastic catheter. Saliva produced
noninvasive measurements that provide immediate in the first 10 s was discarded and the subsequent saliva
results requiring minimal technical expertise (11). was collected for exactly 5 min in a graduated cylinder
Unstimulated whole salivary parameters have been to calculate the flow rate (ml ⁄ min). During the collec-
identified as potential markers of hydration status (12, tion period, all children remained comfortably seated in
13). Reduced salivary flow rate and increased salivary a ventilated and illuminated room. When it was not
osmolality have been shown to be useful to identify possible to collect saliva from a child due to crying, he
dehydration, even when minimal loss of body water or she was excluded. Soon after collection, saliva was
occurs, like during light exercise and heat stress (12). frozen in dry ice, transported to the laboratory and
Unstimulated salivary flow rate and osmolality were stored at )80C until analysis.
demonstrated to strongly correlate with plasma and
urine osmolality (11), which are widely accepted hydra- Blood and urine collection analyses
tion indices (10). Reduced unstimulated salivary flow Blood samples were collected without venostasis from
rate, increased salivary osmolality and total protein an antecubital vein into a separate Vacuteiner tubes
from cerebral palsy individuals could be caused by containing heparin (Becton Dickson, Juiz de Fora,
hypohydration status (14). Brazil). Blood samples were spun at 1500 g for 10 min in
The aim of this study was to evaluate whether a refrigerated centrifuge to obtain plasma, which was
unstimulated salivary flow rate and salivary osmolality immediately stored at )80C until analyses.
from individuals with cerebral palsy correlate with Urine samples were collected into universal containers
plasma and urine osmolality. It was hypothesized that when the child was able to perform this or with probe
if salivary osmolality shows a good correlation with relief they could not.
plasma and urine osmolality, salivary osmolality could
be used as a routine test to identify hydration status in Measurement of salivary, plasma and urine osmolality
CP individuals. parameters
Salivary, plasma and urine osmolality were measured
using a freezing point depression osmometer (Model
Methods Wide-Range Osmometer 3W2, Advanced Instruments,
Subjects Massachusetts, USA).
This project was reviewed by the Human Research
Ethics Committee and approved by the Cruzeiro do SuI Statistical analysis
University Institutional Review Board (IRB) and To evaluate the differences between the groups studied
granted under protocol approval 045 ⁄ 2010. After being in relation to proportions, the chi-square test was used.
informed of the aim of the investigation, written The Student’s t-test was used to verify the hypothesis of
informed consent for participation and publication equality between two groups. When the supposition of
was obtained from the adult responsible for each data normality was rejected, the nonparametric Mann–
individual. Whitney test was used. Spearman’s correlation coeffi-
Thirty-five male and female children, aged 9–13 years cient was used to associate the behavior of four
old, diagnosed with CP who were referred to specialized variables. The significance level was set at P < 0.05.
rehabilitation center, in Sao Paulo, Brazil, were consec-
utively included in this study. The inclusion criteria were
individuals with a clinical medical diagnosis of cerebral
Results
palsy, classified as quadriparesis, diparesis and hemi- The CP group was composed of 57.8% of individuals
paresis (15), and the exclusion criteria were the use of with quadriparesis, 30.6% with diparesis and 11.6%
any drugs that interfere with saliva secretion (anticho- with hemiparesis. The CP and control groups did not
linergic and neuroleptic drugs, benzodiazepines) for at differ significantly regarding sex (P = 0.68) or age
least 72 h prior to examination, a history of head (P = 0.59) (Table 1).
and neck radiation and surgical procedures to reduce Data of salivary flow rate (ml ⁄ min) and salivary,
drooling. plasma, and urine osmolality (mOsm ⁄ kg H2O) from
The control group consisted of 27 nondisabled CP and control groups are presented in Table 2. CP
children, aged 10–12 years old, and the primary inclu- children presented a reduction in salivary flow rate
sion criterion was absence of neurological damage. (50%) compared to the control group (P < 0.01).
None of the participants reported any complaint Moreover, an increase salivary (50%), plasma (3%),
suggestive of salivary-gland dysfunction or were using and urine osmolality (20%) was observed in the CP
any medication that could affect salivary secretion. group compared to the control group (P < 0.001).
The caregivers from both groups were previously Table 3 and Figs 1 and 2 show the values of the
advised that the children should receive normal feeding Spearman correlation coefficient for the values of
and water as in their usual daily routine. Samples were salivary flow rate, salivary, plasma and urine osmolality
collected in the first period of the morning in the of the two groups studied. The salivary flow rate
following sequence: saliva, blood and urine. was negatively correlated with salivary, plasma and

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 Saliva and hydration status in cerebral palsied
Santos et al.

584
Table 1 Distribution of cerebral palsy and control children according
to sex and age Discussion
A previous study by our group demonstrated that the
Cerebral palsy Control saliva of individuals with CP has increased salivary
(n = 35) (n = 27) P-value* osmolality, total protein concentration and reduced
Sex, n (%) salivary flow rate, suggesting a state of hypohydration in
Female 20 (57.1%) 14 (51.9%) 0.68a these individuals (14). These results led us to question
Male 15 (42.9%) 13 (48.1%) whether the salivary parameters could be correlated with
Age (years) 11.5 ± 2.1 11.2 ± 1.1 0.59b
other indicators of hypohydration, for example, plasma
a
The data was compared by chi-square test. and urine osmolality. In fact, the present results verified
b
The data was compared by Student’s t-test. that salivary osmolality is a reliable parameter for
*P > 0.05. evaluating hydration status in CP individuals, since it
correlates with plasma and urine osmolality. Further-
more, the reduction in salivary flow rate, often observed
Table 2 Salivary flow rate (ml ⁄ min) and salivary, plasma, and urine in CP individuals (4–6), can also be related to osmolality
osmolality (mOsm ⁄ kg H2O) for cerebral palsy and control children
variations.
The physiological regulation of total body water
Parameters Cerebral palsy Control P value* volume and fluid concentration is a complex and
Salivary flow rate 0.56 ± 0.24 1.16 ± 0.22 <0.001 dynamic process, which makes it difficult to establish a
Saliva osmolality 86.5 ± 11.1 57.7 ± 8.0 <0.001 gold standard for hydration assessment.
Plasma osmolality 294.0 ± 4.2 286.1 ± 3.0 <0.001 Osmolality is the number of osmotically active par-
Urine osmolality 925.6 ± 120.3 748.2 ± 121.1 <0.001
ticles of solute contained in 1 l of solution and it is
Mean (±SD). expressed in milliosmoles of solute particles per kilo-
*Mann–Whitney’s test comparing cerebral palsy and control groups gram of water. Plasma osmolality is the usual maker of
P < 0.05. hypohydration for several conditions, such as associated
with age (16), water and food deprivation (17), progres-
sive acute dehydration and post-exercise (12, 13).
Table 3 Values for Spearman’s correlation coefficient between the Plasma and urine osmolality have been described as
values of salivary flow rate, salivary, plasma and urine osmolality.
useful tools to identify hydration status (9, 18); however,
they are somewhat invasive and need the individual’s
Salivary Plasma Urine cooperation. Taking blood samples in CP individuals is
osmolality osmolality osmolality
a hard task due to the presence of their involuntary
Salivary flow rate (ml ⁄ min) )0.75* )0.68* )0.41* movements; while urine collection is also difficult, since
Salivary osmolality (m0sml) – 0.72* 0.47* CP individuals may not present voluntary control of
Plasma osmolality (m0sml) – 0.66* their urethral sphincter, requiring catheterization.
*Spearman’s correlation coefficient, P < 0.01. Saliva has been studied as a tool for the diagnosis of a
healthy condition or disease status (19, 20). Some
salivary biomarkers, including DNA, RNA, proteins,
immunoglobulin, metabolites, cellular material, have
urine osmolality (P < 0.01). Salivary osmolality corre- been used for diagnosing microbiological infection, head
lated positively with plasma and urine osmolality and neck carcinoma, cardiovascular and autoimmune
(P < 0.01). disease, periodontitis and for monitoring and detecting

A 1.60 r = –0.75 B 1.60 r = –0.68 C 1.60 r = –0.41

1.40 1.40 1.40

Salivary flow rate

Salivary flow rate

Salivary flow rate

1.20 1.20 1.20

1.00 1.00 1.00

0.80 0.80 0.80

0.60 0.60 0.60

0.40 0.40 0.40

Groups Groups Groups
CP CP CP
0.20 Control 0.20 Control 0.20 Control

40 50 60 70 80 90 100 110 280 290 300 310 500 600 700 800 900 1000 1100 1200
Salivary osmolality Plasma osmolality Urine osmolality

Figure 1 Illustration of Spearman’s correlation comparing the salivary flow rate and salivary (A), plasma (B), and urine (C) osmolality for control
(s) and cerebral palsy (d) individuals (R = Spearman’s correlation coefficient, P < 0.01).

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 Saliva and hydration status in cerebral palsied
Santos et al.

585
A 110 r = 0.72 B 110 r = 0.47 C r = 0.66

100 100 310

Salivary osmolality

Salivary osmolality

Plasma osmolality
90 90
300
80 80

70 70
290
60 60

50 50
280
Groups Groups Groups
CP CP CP
40 Control 40 Control Control

280 290 300 310 500 600 700 800 900 1000 1100 1200 500 600 700 800 900 1000 1100 1200
Plasma osmolality Urine osmolality Urine osmolality

Figure 2 Illustration of Spearman’s correlation between salivary, plasma and urine osmolality values for control (s) and cerebral palsy (d)
individuals (R = Spearman’s correlation coefficient, P < 0.01).

drugs in the body (19, 20). The present study showed significantly lower than that of healthy controls, with
that salivary osmolality reflects plasma and urine protein and sialic acid levels significantly higher (27). In
osmolality. Salivary, urine and plasma osmolality all the present study, the reduction in salivary flow rate,
presented a negative correlation with the salivary flow previously reported in the literature in CP individuals,
rate in CP individuals. was confirmed and could be associated with the hypo-
Hypohydration is a condition presented in CP hydration condition. The alterations in salivary flow
individuals probably due to the fact that they are rate could explain the changes in the composition of
mainly dependent on the initiative of their caregivers to saliva from CP individuals published previously (4–7).
offer them liquids; they usually do not complain of In conclusion, cerebral palsy children seem to present
thirst and can hardly drink water by themselves, impaired adequate hydration status, as verified by
moreover, it is difficult for them to swallow all the increased salivary, urine and plasma osmolality. Since
water that is offered (21). These difficulties involved in the possible hypohydration condition may be reflected
CP justify the use of saliva to monitor systemic in saliva fluid, which could compromise the protective
conditions. The collection of saliva is an excellent and function exerted by saliva, the earlier this condition is
noninvasive option, because these individuals have identified the greater the chances of administering
distinctive characteristics, such as motor dysfunction preventive measures. Moreover, salivary osmolality is
and poor cooperation, which make it difficult to collect a reliable parameter that reflects changes in plasma and
urine, blood or other body fluids. urine
Salivary fluid and electrolytes secretions occur in the
acinar cells and along the duct system of salivary glands.
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J Oral Pathol Med