hyposalivation is the reduction of salivary flow and can be assessed by specific exams , 
 such as sialometry method , while xerostomia is rather a subjective 
 feeling of oral dryness . the latter is however not necessarily related to a reduction of 
 salivary flow , because this symptom has also been reported by patients who did not 
 present with hyposalivation . the etiology is 
 associated with drugs that inhibit salivary flow , like psychotropics , with autoimmune 
 diseases , like sjgren 's syndrome , and with head and neck radiation therapy . moreover , chronic 
 anxiety , depression , hemodialysis , diabetes mellitus and dehydration can also be 
 associated . the reduction 
 of salivary flow may also induce oral mucosa infection like candida 
 spp . and , furthermore , increases the number of dental caries . during anamnesis and oral examination , symptoms include a burning feeling of the tongue , dysphonia , an 
 increase in the frequency of liquid intake and dysphagia . signals are the presence of small 
 amounts of frothy , thick or sticking saliva , fissuring and atrophy of the filiform 
 papillae , erythematous mucosal areas , halitosis and oral mucosal dryness . as a consequence , clinical diagnosis of hyposalivation in addition , other complementary methods like sialometry , 
 sialochemistry and sialography are accurate for the diagnosis of 
 hyposalivation . however , these methods are difficult to carry out in 
 hospitalized patients considering their physical limitations . furthermore , some studies 
 have found that only clinical examinations , including subjective reports , can be highly 
 indicative of hyposalivation without any complementary method . the majority of hospitalized patients have physical limitations and systemic diseases 
 justifying the use of several drugs . most of such drugs are associated with the 
 emergence and/or worsening of hyposalivation , as such that simple and rapid clinical 
 diagnosis of this condition becomes essential . yet , hardly any study has dealt with the 
 development of a simple clinical diagnostic tool to simply and reliably detect cases of 
 hyposalivation in a hospitalized population . therefore , this study aimed to evaluate the 
 effectiveness of clinical criteria that are strongly correlated to the diagnosis of 
 hyposalivation in hospitalized patients . this study was approved by the research ethics committee of the school of dentistry , 
 pontifical catholic university of paran ( pucpr ) , brazil . the initial population consisted of 221 hospitalized patients , aged 20 to 90 years , 
 admitted to two university hospitals from curitiba , pr , brazil , due to several medical 
 reasons , between february and may 2008 . exclusion criteria included salivary gland removal , head and neck radiation 
 therapy , cholinergic drug intake and cognitive deficit , like alzheimer 's disease in an 
 advanced stage . the final sample consisted of 145 patients , 48 males and 97 females 
 ( mean age 54.115.7 years , range : 21 - 88 years ) . each patient was examined in the morning 
 and in the afternoon , during only 1 day . first , xerostomia complaints , considered as potential reference symptoms , were 
 recorded followed by evaluation of chewing and dysphagia difficulties of dry foods and 
 the increase in the frequency of liquid intake through anamnesis ( figure 1 ) . afterwards , cheek mucosa dryness was evaluated by visual 
 inspection , palpation and adherence degree of mucosal surface using a wooden spatula . the presence of a saliva pool accumulated on the floor of the mouth and salivary 
 secretion during extraoral parotid glands stimulation by the palpation method , were 
 assessed by oral inspection . all clinical information was obtained and adapted according 
 to the data in previous studies . clinical assessment was carried out between 09:00 and 11:30 
 ( morning ) and between 1:30 and 3:00 ( afternoon ) , considering the potential influence of 
 the circadian cycle on the patients ' saliva production . information concerning the symptoms of xerostomia , 
 chewing , dysphagia and the increasing of liquid intake was obtained only in the 
 morning . anamnesis focused on hyposalivation data were analyzed using chi - square tests with a significance level of 5% . results showed that from 145 
 patients , 71 ( 48.9% ) presented with xerostomia complaints . from these 71 patients , 30 
 ( 42.3% ) presented with difficulties during chewing , 30 ( 42.3% ) during swallowing , while 
 48 ( 67.6% ) reported an increase in the frequency of liquid intake . relation between xerostomia complaint and chewing difficulty , dysphagia and 
 increased frequency of liquid intake tables 2 , 3 and 4 show the results of patients 
 who presented mucosa of the cheeks and floor of the mouth dryness and absence of 
 salivary secretion during parotid glands stimulation , respectively . data obtained in the 
 morning and in the afternoon , are presented separately in these tables . these findings 
 showed that there was statistically significant correlation among the variables 
 ( p<0.05 ) . relation between xerostomia complaint and total number of patients with mucosa of 
 the cheeks dryness in the morning and in the afternoon note : value of p<0.05 shows statistical correlation among the variables relation between xerostomia complaint and total number of patients with floor of 
 the mouth dryness note : value of p<0.05 shows statistical correlation among the variables relation between xerostomia complaint and total number of patients without 
 salivary secretion during parotid glands stimulation note : value of p<0.05 shows statistical correlation among the variables the present study showed that almost half of the total sample ( n=71 ) ( table 1 ) , presented with clinical signs and 
 symptoms of xerostomia . despite the fact that this symptom is not considered determinant 
 of hyposalivation , xerostomia symptoms present subjective complaints of hospitalized 
 patients that should be diagnosed timely . previous studies confirm that 
 hyposalivation is one of the most frequent problem amongst those patients . in the same 
 way , some authors have reported that during anamnesis , simple questions regarding 
 xerostomia might be useful as a reliable predictor of hyposalivation . ( 2010 ) evaluated the prevalence of dry mouth and taste disturbance , salivary flow rate 
 and oral mucosal lesions in institutionalized and non - institutionalized elderly and 
 concluded that the institutionalized population is significantly more affected by dry 
 mouth and taste disturbance complaints , decreased salivary flow rate and oral mucosal 
 diseases when compared with the other group . although xerostomia is considered as a 
 subjective complaint , the present study applied it as a reference symptom , considering 
 its clinical relevance for hospitalized medically compromised patients . usually , such 
 patients do not drink , eat , or even speak and the quality of life during the 
 hospitalization period becomes worse daily . in fact , the present results showed that 
 xerostomia had a significant correlation with chewing and swallowing difficulties and 
 with an increase in the frequency of liquid intake confirming the results from previous 
 studies . ( 1987 ) considered the xerostomia subjective complaint as 
 a valuable tool to identify patients who require additional salivary gland evaluation . this aspect becomes more important in hospitalized patients because , most often , they 
 are taking several systemic drugs whose side effects can compromise the function of 
 salivary glands . the fact of xerostomia is considered a subjective symptom was clearly observed in the 
 current study . tables 1 - 4 show that patients who did not have xerostomia complaint , also 
 presented its classical signals and symptoms , for instance , chewing difficulty ( 5.4% ) , 
 dysphagia ( 8.1% ) , increased frequency of liquid intake ( 13.5% ) , cheek mucosa dryness 
 ( 29.7% and 20.3% ) and floor of the mouth dryness ( 29.7% and 20.2% ) , and parotid gland 
 stimulation ( 34.7% and 20.3% ) . however , it is also possible to see in the same tables 
 that the presence of all these classical signals and symptoms in the patients who 
 presented with xerostomia complaint was significantly higher . the clinical data obtained during oral examination were associated with xerostomia in 
 the morning and in the afternoon . when this symptom was compared with cheek mucosa and 
 floor of the mouth dryness , and with the absence of salivary secretion during parotid 
 glands stimulation , it was observed that a significant number of patients showed these 
 clinical signals in both measuring moments ( tables 
 2 , 3 and 4 ) . these results can be considered highly suggestive of 
 hyposalivation according longman , et al . ( 1992 ) , especially if they are observed at the same time and in 
 two periods of evaluation , in the morning and in the afternoon , as in the present 
 study . considering that the current research is an initial study , each patient was examined in 
 the morning and in the afternoon , during only 1 day . however , it is important to state 
 that further researches are necessary to evaluate hyposalivation in hospitalized 
 patients on a daily basis , as each patient might be examined during the entire period of 
 their hospitalization . dawes ( 1975 ) carried out a study 
 regarding the influence of the circadian cycle on salivary composition and salivary 
 flow , stimulated and non - stimulated , taking into account 5 evaluations 
 per day during 11 days in each patient . in dawes ' study , the 
 non - stimulated saliva group showed differences in flow rate and sodium , potassium , 
 magnesium , chloride and inorganic phosphate concentrations but not in protein and 
 calcium . in contrast , the stimulated saliva group did not show differences only in 
 protein concentration . in the current study , the circadian cycle did not present 
 significant influence on the results considering the small difference of percentages 
 between both periods ( tables 2 , 3 and 4 ) . yet , patients were examined only twice in one day , as such that no definite conclusion 
 regarding the circadian cycle could be presented . however , the physical limitations 
 presented by hospitalized patients in the current study did not allow several 
 evaluations of salivary flow per day . consequently , simple methods to diagnose hyposalivation , as used in the present study , 
 could easily spot patients with this problem , as such to more effectively and 
 immediately provide therapy like dry mouth solutions , rinses , toothpastes , salivary 
 substitutes and avoid any further problems in already compromised patients . several 
 authors cited that it is very important to 
 identify the causative agent and the appropriate therapy to hyposalivation , which 
 includes increasing oral hydration and the use of systemic cholinergic drugs , 
 stimulants , lubricants and more recently acupuncture . in addition to theses aspects , 
 hyposalivation may predispose infection diseases like candidiasis , which can be more 
 aggressive in hospitalized patients requiring special oral care . the clinical criteria considered in this study showed to be valuable for a simple 
 clinical diagnosis of hyposalivation in hospitalized patients . in the hospital 
 environment , such a simple exam could avoid more invasive and exhausting exams . on the 
 other hand , for those patients who do not present these classical findings , oral 
 examination could be a valuable exam that might indicate the need for other specific 
 exams , such as sialometry , sialochemistry and sialography . furthermore , the oral 
 examination , including xerostomia investigation , could be at least indicative for 
 supportive therapy , for instance the use of artificial saliva or other methods that 
 could help salivary glands stimulation . ( 1994 ) evaluated the effectiveness of a 
 test toothpaste containing the lactoperoxidase system , compared to a normal fluoridated 
 toothpaste in xerostomic patients , demonstrating the efficacy of the lactoperoxidase 
 system administered by a toothpaste , on supragingival plaque control in those 
 patients . the findings of the oral examination confirm the results of a previous study , which showed that oral mucous dryness , 
 diagnosed by a clinical dentist , can help identifying patients with salivary flow 
 changes , without necessitating the use of sialometry . moreover , these clinical findings 
 of hyposalivation aid the identification of patients who need a specific medical 
 evaluation to diagnose possible systemic diseases such as sjgren 's syndrome . as far as the literature could be explored , the majority of epidemiological studies 
 concerning hyposalivation diagnosis is carried out in outdoor patients . so far , a small number of studies have been performed 
 on medically compromised hospitalized patients . as a consequence , studies reporting on oral clinical 
 findings of hyposalivation in the hospital environment are necessary for a better 
 diagnosis and treatment of this condition in hospitalized patients . in conclusion , the results of the present study show that the clinical diagnosis of 
 hyposalivation in hospitalized patients is feasible and has a great clinical relevance . 
 indeed , the simple and quick diagnosis may allow to immediately starting an appropriate 
 therapy for hyposalivation , thus improving the quality of life in hospitalized patients . 
 furthermore , the clinical diagnostic criteria are simple and non - invasive , creating the 
 possibility for delegation to other health professionals like the nursing staff . further 
 studies should attempt to address the necessity to teach health professionals , who are 
 involved in a multidisciplinary care , how to make a feasible and reliable diagnosis of 
 hyposalivation in hospitalized patients . the oral health of hospitalized patients should 
 indeed be considered an important aspect contributing to the overall health of those 
 patients .
objective the aim of this study was to evaluate the effectiveness of clinical criteria for 
 the diagnosis of hyposalivation in hospitalized patients . 
 material and methods a clinical study was carried out on 145 subjects ( 48 males ; 97 females ; aged 20 
 to 90 years ) . 
 each subject was clinically examined , in the morning and in the 
 afternoon , along 1 day . 
 a focused anamnesis allowed identifying symptoms of 
 hyposalivation , like xerostomia complaints ( considered as a reference symptom ) , 
 chewing difficulty , dysphagia and increased frequency of liquid intake . 
 afterwards , dryness of the mucosa of the cheecks and floor of the mouth , as well 
 as salivary secretion during parotid gland stimulation were assessed during oral 
 examination . 
 results results obtained with chi - square tests showed that 71 patients ( 48.9% ) presented 
 xerostomia complaints , with a significant correlation with all hyposalivation 
 symptoms ( p<0.05 ) . 
 furthermore , xerostomia was also significantly correlated 
 with all data obtained during oral examination in both periods of evaluation 
 ( p<0.05 ) . 
 conclusion clinical diagnosis of hyposalivation in hospitalized patients is feasible and can 
 provide an immediate and appropriate therapy avoiding further problems and 
 improving their quality of life .