Accepted Manuscript

Title: Masticatory efficiency and bite force in individuals with

normal occlusion

Author: Rogério Alexandre Modesto de Abreu Max

Domingues Pereira Fabianne Furtado Gabriela Pereira Ribeiro
Prado Wilson Mestriner Junior Lydia Masako Ferreira

PII: S0003-9969(14)00107-1
DOI: http://dx.doi.org/doi:10.1016/j.archoralbio.2014.05.005
Reference: AOB 3178

To appear in: Archives of Oral Biology

Received date: 17-7-2013

Revised date: 25-4-2014
Accepted date: 5-5-2014

Please cite this article as: Abreu RAM, Pereira MD, Furtado F, Prado GPR, Junior WM,
Ferreira LM, Masticatory efficiency and bite force in individuals with normal occlusion,
Archives of Oral Biology (2014), http://dx.doi.org/10.1016/j.archoralbio.2014.05.005

This is a PDF file of an unedited manuscript that has been accepted for publication.
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*Title Page

Masticatory efficiency and bite force in individuals with normal occlusion

Running Title: Normal occlusion efficiency

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Rogério Alexandre Modesto de Abreu,1 Max Domingues Pereira,1 Fabianne Furtado,1 Gabriela

Pereira Ribeiro Prado,1 Wilson Mestriner Junior,2 Lydia Masako Ferreira1

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1
Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Department of Clinical Pediatrics and Preventive and Sanitary Dentistry, College of Dentistry,

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Universidade de São Paulo, Campus Ribeirão Preto (USP-RP), SP, Brazil
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Corresponding author:
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Max Domingues Pereira

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Division of Plastic Surgery

Rua Napoleão de Barros 715, 4o. andar

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CEP 04024-0002, São Paulo, SP, Brazil.

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Tel.: +55 (11) 5576-4118; Fax: +55 (11) 5575-8265

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e-mail: maxdp@terra.com.br

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Masticatory efficiency and bite force in individuals with normal occlusion

Abstract

Objective: To evaluate and correlate masticatory efficiency and maximum bite force in adult

individuals of both genders with normal occlusion.

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Design: The study was conducted in a university research center. Masticatory efficiency and

maximum bite force were evaluated in 55 adults (27 men and 28 women) with normal

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occlusion. All subjects chewed four fuchsin capsules (two on the right and two on the left

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molar region) for 15 chewing cycles with a 3-minute interval between capsules. The

concentration of fuchsin in the capsules was determined by spectrophotometry and stratified

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by gender and chewing side. Bite force was measured three times on both the left and right

molars; the highest value of the three measurements on each side was taken as the maximum
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bite force.

Results: Masticatory efficiency was higher in women (right side, 1.17 ± 016 µg/ml; left side,
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1.20 ± 0.15 µg/ml) than in men (right side, 0.92 ± 0.24 µg/ml; left side, 0.89 ± 0.24 µg/ml).
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The maximum bite force was higher in men (right side, 632 ± 174 N; left side, 627 ± 170 N)
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compared with women (right side, 427 ± 140 N; left side, 420 ± 112 N). No significant
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differences in chewing efficiency and bite force were found between sides for both genders.

Conclusions: Women showed highest masticatory efficiency, while men had the highest
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maximum bite force, with no correlation between these two parameters among genders.

Keywords: Bite force, dental occlusion.

Page 2 of 31
1. Introduction

Maximum bite force (MBF) measurement can be used as a parameter indicating the

functional condition of the masticatory system1, 2. For those working in the field of oral and

maxillofacial surgery, it can also be used as a parameter of normality3.

The masticatory efficiency (ME), also referred to as masticatory or chewing

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performance4, is the ability of an individual’s masticatory system to reduce food to small

particles to be swallowed. It is a complex task affected by many factors including bite or

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occlusal forces, occluding teeth, mandible kinematics, tongue work and salivary activigy2-4.

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The ME has been recognized as having a direct impact on quality of life and previous

studies have been used a number of methods to determine to what degree the study

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participant’s masticatory system could grind the study chewing material 2, 3, 4.

ME has been most frequently determine using solid hard food, such as carrots5,
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peanuts6 and coconut7. After these materials being chewed for a period of time3 or chewing

cycles 5, 6, the resulting ground product is collected and usually separated in size ranges using
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sieves with different, calibrated openings. The separated portions, referred to as fractions, of
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the ground material is weighed and the rates determined are recorded for analysis 5, 6, 7.
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Attempts to improve ME determination in order to provide higher levels of

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reproducibility by eliminating influencing factors such as salivation activity, which makes

grinding more effective by softening and/or dispersing the material chewed, and by
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controlling for the variability of hardness of the natural materials used led to the introduction

of artificial materials for chewing such as Optosil™, Cuttersil™ and Optocal™ 4, 8-12.

Further improvement was carried out aiming at replacing the sieving and weighing of

the material chewed by a more convenient way to evidence the grinding ability of a study

participant. The use of rubber capsules containing pigment-coated granules as a test material

was introduced by Nakasima et al.14. Other colorimetric and spectrophotometric methods have

also been used to assess ME3,7,13.

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 The method developed by Escudeiro-Santos et al.13 combines colorimetric indication

of grinding efficiency with teeth crushing work. Artificial granules (beads) manufactured with

natural components designed to have a controlled level of hardness are encased in a resistant,

leak-proof polyvinyl acetate capsule. Chewing on this capsule crushes the beads in a fashion

similar to that regular hard food is crushed. When the beads are reduced to smaller particles a

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dry coloring substance (fuchsin) is exposed on the surface of these particles. As it occurs with

food, which after chewing becomes more exposed to digesting body secretion, the breaking

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down of the beads makes the coloring material more easily extract by using a convenient

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solution. The exposed dye incorporate in the liquid means proportionally to the size of the

crumbled particle, thus indicating to what degree the beads were ground.

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The chewing capsules developed by the team of Escudeiro-Santos should fulfill three

major research requirements, first the elimination of bias in experimental reproducibility

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introduced by the variability in the level of salivation and saliva activity, second the

elimination of bias in experimental reproducibility introduced by the variability in the level of

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hardness of the material chewed, and finally the reduction of costs and laboratory workload
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by using a cheaper and less demanding method of determining ME.

Studies using Escudero’s capsules are few. These have determined reproducibility3, 7
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and equivalence with other methods of assessing ME13. None of them have investigated the
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correlation between ME and other parameters of masticatory function. On the other hand, the
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literature includes many studies focusing on the association between mean values of

maximum BF and ME15, 16, 17, 18.

An aspect common to the studies retrieved is that they have found an association

between BF and ME in terms of mean values obtained for comparing groups (inter-groups

comparison). 5,9,11,15-18. They have not explicitly reported on the variation of BF and ME in a

same group. They also show some controversy regarding BF-ME. Despite reporting higher

levels of BF in male groups19-24 as compared with female counterparts, some found higher

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masticatory performance in men’s groups 15,16, whereas other studies reported similar rates for

male and female participants5, 9,11,17,18.

The aim of the present study was to determine whether an association between

maximum BF and ME in healthy dentate individuals with normal occlusion could be

evidenced using PVA capsules developed by the research team of Escudeiro-Santos et al.13 to

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assess ME.

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2. Materials and methods

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The study was approved by the Research Ethics Committee of the Universidade

Federal de São Paulo (UNIFESP), Brazil (approval number CEP 0472/10) and performed in

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accordance with the ethical standards of the 1964 Declaration of Helsinki and its subsequent

amendments. Written informed consent was obtained from all participants prior to their
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inclusion in the study, and anonymity was ensured.

Fifty-five volunteers (27 men and 28 women) without dentofacial deformities, with
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normal occlusion and mean age of 28.05 ± 4.04 years (range, 18-40 years) were consecutively
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recruited in the Cranio-maxillofacial Surgery Unit of the Plastic Surgery Outpatient Clinic at
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UNIFESP. The volunteers included medical students, resident physicians and post-operative
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patients that had not undergone cosmetic any surgical procedure related to the maxillofacial

topology
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The study included adults with at least 14 permanent teeth in each arch, Class I first

molar and canine relationships (Angle Classification) 25, and Class I facial pattern, according

to Capelozza Filho.26

Exclusion criteria were:

• Changes in the temporomandibular joint (TMJ), such as pain, limited oral opening, TMJ

sounds (clicking or popping), bruxism, and dental restorations affecting occlusion

• Use of fixed or removable prostheses

• Orthodontic treatment in the past three years

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• Prior orthognathic surgery

• Traumatic or congenital facial deformities, or tumors of the maxilla and mandible

All volunteers were clinically examined and completed a questionnaire assessing their

demographic characteristics (age, gender, and ethnicity) medical history, and chewing side

preferences. Individuals who reported any pain on clinical examination and those with any

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TMJ sounds, such as popping or clicking, were not included in the study.

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2.1. Procedures

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Facial photographs of all participants were taken in standardized views (frontal view

and right and left lateral views), as well as intraoral photographs (frontal view, right and left

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buccal views, and upper and lower occlusal views). The photographs were evaluated by an

orthodontist, who assessed the number of teeth, tooth wear, and defective restorations to
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determine whether the participants had normal occlusion and Class I facial profile according

to Capelozza Filho.26
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PVA capsules measuring 6.7 mm in thickness, 10 mm in width, and 20 mm in length,

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with a mean weight of 250 mg, containing fuchsin granules about 1 mm in diameter were
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used to assess masticatory efficiency (Fig. 1).

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The fuchsin granules (or beads) were obtained by a dripping process and ionotropic

gelation of a 2% aqueous dispersion of pectin containing 50% solids and fuchsin stain. The
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dispersion was dropped into a 1.0 M calcium chloride solution. The granules were then coated

with 5% Eudragit E100 in a solution of 10% acetone and absolute ethanol. Approximately

250 mg of granules were packed into each PVA capsule. All fuchsin capsules were obtained

from the same batch and all production procedures, quality control, and validation of the

product were performed by the Pharmacology Laboratory of the School of Pharmaceutical

Sciences of Ribeirão Preto, University of São Paulo (USP Ribeirão Preto), Brazil.

As established in a pilot study including 10 individuals (5 men and 5 women) to

verify reproducibility, which showed no statistical difference in outcome between chewing

Page 6 of 31
the first and second PVA capsules on either right or left side of the masticatory apparatus, all

subjects chewed four capsules (two on the right and two on the left molar region) with an

interval of three minutes between capsules. Each capsule was chewed for 15 chewing cycles.

The participants were seated on a chair with their feet flat on the floor, so that they could

chew the capsules in the most natural way possible. Prior to chewing the first capsule, the

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participants chewed a sugarless chewing gum to erase the resting neuromuscular memory, so

that the chewing was as close as possible of normal mastication.

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The chewing of the capsule crushed the contained granules, spreading fuchsin inside

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the capsule in proportion to the masticatory energy. Masticatory efficiency was determined

based on the fuchsin concentration within the capsules. The PVA capsule wall was not

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damaged during chewing, and therefore no loss of granules occurred.

After the chewing, each capsule was labeled, stored in a dark container, and sent for
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laboratory analysis. The 220 capsules (55 participants, 4 capsules per participant) were then

analyzed by the Pharmacology Laboratory (USP Ribeirão Preto). The content of each capsule
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was dissolved in 5 ml of water and stirred for 30 seconds. The solution was then filtered with
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qualitative filter paper and dye concentration was determined using a UV-visible
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spectrophotometer (Beckman DU-640, Beckman Inc., Fullerton, CA) by measuring the

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absorbance of the solution at 546 nm.

From the absorbance values, the fuchsin dye concentration can be calculated using the
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equation: x = (y +0.0045)/0.167,28 where y is the absorbance of the solution at 546 nm and x is

the dye concentration (µg/ml). Thus, for each capsule chewed, a fuchsin concentration

proportional to the masticatory efficiency was obtained. Mean fuchsin concentration was then

calculated for both the right and left chewing sides for each gender.

The maximum bite force expressed in newtons (N) was measured using a digital

unilateral dynamometer adapted for oral use (DDK 100, Kratos Industrial Ltda., Cotia, São

Paulo, Brazil) with a capacity of 100 kgf (1000 N). The dynamometer contains a bite fork

attached to its extremity with two 6-mm thick blades spaced 3.0 mm apart from each other.

Page 7 of 31
The dynamometer has been certified by the Brazilian standards institute (calibration number

1309802/12, calibration date 29/02/2012). Bite force was measured three times on both the

left and right molars. For each participant, the highest value of the three measurements on

each side was taken as the maximum bite force.19-21 All bite force measurements were

performed after the masticatory efficiency assessment.

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2.2 Statistical analysis

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The sample size was calculated based on a pilot study with 10 individuals (5 men and

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5 women) with normal occlusion. The maximum variation in fuchsin concentration within the

capsules for both the right and left chewing sides was 0.18µg/ml. A fuchsin concentration of

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0.20 µg/ml was considered to be the minimum significant difference between test conditions.

Setting the confidence interval at 95% and the power of the sample at 90%, the sample size of
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34 participants (17 individuals per gender) would be required to detect differences between

groups. Fifty-five individuals (27 men and 28 women) were selected to participate in the
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study.
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The Kolmogorov-Smirnov statistics was used to test for normality of distribution of

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fuchsin concentration and maximum bite force per gender.

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Analysis of variance (ANOVA) with level of significance set to less than .05 was used

to determine statistical differences in fuchsin concentration and maximum bite force scores in
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comparisons regarding sides and genders.

The correlation between maximum bite force and masticatory efficiency indirectly

measured as the concentration of fuchsin in each chewing side in either gender was assessed

using Pearson’s linear coefficient.

All statistical tests were performed at a significance level of 0.05 (p < 0.05).

3. Results

Most participants were Caucasians and had chewing side preferences (Table 1).

Page 8 of 31
 The Kolmogov-Smirnov test indicated that the distributions of MBF and fuchsin

concentration values within their ranges of variation were compatible with the normal

distribution. (Table 2)

No statistically significant differences in chewing efficiency and maximum bite force

were found when comparing chewing sides for both genders (Table 2).

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The mean concentration of fuchsin in both sides was significantly higher for women

than for men (p < 0.05). Men had significantly higher (p < 0.05) maximum bite force in both

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sides compared with women (Table 2).

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There was no statistically significant correlation between masticatory efficiency

measured as concentration of fuchsin and maximum bite force either for men or women (p

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ranging from 0.538 to 0.662) (Table 2 and Chart1).
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4. Discussion

Escudeiro-Santos and colleagues13 have developed an elegant device for determining

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masticatory efficiency (ME). Elegant because it is not based on chewing of bits of hard food
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and therefore does not require the spitting of chewed material, nor the labor of sieving the
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particles chewed for determining the patient’s efficacy of crushing and grinding. The device
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consists of an unbreakable polyvinyl acetate (PVA) capsule containing 1-milimeter beads that

incorporate fuchsin in their composition. Fuchsin is a dye that is liberated in amounts

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proportional to the mastication work on the capsule.

Since the report on the development and reproducibility of measurements13of

Escudeiro and colleagues’ capsule (Ecap), a few studies have been carried out using them to

assess ME – correlation between Ecap and sieve methods to assess ME7,12, analysis of

masticatory movements4, masticatory efficiency of complete denture prosthesis32,

assessment of ME in individuals with class II and III occlusion33, and correlation between

ME and muscle electroactivity3.

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 As members of a multidisciplinary team of facial reconstruction, the authors of the

present study viewed Ecap as a labor saving tool that could help them with establishing

normal levels of ME, an issue focused more closely by orthodontists. On the other hand,

maximal bite force (MBF) assessment is viewed by surgeons as an indicative measurement of

surgical outcome. Therefore, the integration of these two views seemed to be a useful task for

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a multidisciplinary team to accomplish, if possible

The association between MBF and ME seems to be a matter of disagreement among

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investigators. Some studies comparing groups with different characteristics, e.g. men and

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women, report higher levels of MBF associated with higher ME15,16,31. On the other hand,

it is common to retrieve studies showing that groups with higher and lower MBF average had

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similar ME average5,6,9,11,17,18,34. There are still a few that found no relationship between

MBF and ME averages6,17.However, investigators experienced with observing chewing

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movements have concluded that ME is mostly related to masticatorty cycle kinematics,

although an association between ME and maximal bite force (MBF) have also been reported
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by them18. As to the presently reported exploratory study, it was not conceived to settle the
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issue but to determine what could be evidenced by using Ecaps, an alternative device to
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measure ME.
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In the present study, the measurement of MBF was taken between molars in a sample

of mostly Caucasian men and women with nearly all declaring no preference of side for
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chewing. The measures collected did not include unexpected levels. Male and female MBF

means showed no statistically significant difference regarding side and averaged 630N and

424N for men and women, respectively (details in Table 2). These finding were similar to that

reported in previous studies.19,20,31. Regalo et al.19 used the same model of dynamometer

that was used in this study and found a MBF average of 505 ± 53 N in the right molar region

and 464 ± 53N in the left molar region in men, and 315 ± 65 N in the right molar region and

262 ± 36 N in the left molar region in women. Palinkas et al.20 reported a MBF mean of 339

± 32 N in the right molar region and 348 ± 30 N in the left molar region in men and 221 ± 31

Page 10 of 31
N in the right molar region and 247 ± 31 N in the left molar region in women. These studies

show that MBF assessed in populations with similar characteristics can vary by as much as

200N, but still indicate higher levels for men as compared with women.

ME or the ability to reduce hard food to crumbs by crushing and grinding involves 4

major features, bite force applied, occlusion or contact between upper and lower teeth,

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mandible kinematics, and extent of chewing (i.e. chewing length of time or number of

chewing strokes applied). Once establishing a fixed extent of chewing, reproducibility of ME

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will very much depend on the person whose chewing ability is assessed, because it is the

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individual being assessed that determines the force applied and the regularity of mastication

movements. Obtaining strict reproducibility of ME at the same time that subjects are left to

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chew in their habitual fashion may require an initial large sample and filtering of data.

Investigators frequently have to ponder whether the number of measurements necessary for a
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strict level of reproducibility would exceed the limit of time and/or costs set for the study, or

whether establishing a lower level of reproducibility, if any level at all, would not alter the
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conclusion drawn from the experiment to carry out.

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In order to establish the number of ME assessments to be used in the present study, a

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group of 10 subjects (5 male and 5 female) were asked to chew on one Ecap on the right side
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for 15 mastication cycles, and to repeat the procedure on the left side using another Ecap. ME

averages were calculated. A second run of the experiment was carried out and corresponding
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averages were determined. ME averages of the two runs were compared again. Additional

runs would follow until the average of the series stabilize. After the second run, though, no

statistically significant differences were found. This finding determined the end point of the

experiment and established that our study would carry out 2 ME assessments per side per

participant.

The analysis of the double ME assessments per side per subject carried out in the

whole range of the study sample showed no statistically significant difference in the average

rates of fuchsin concentration referring to the right and left side, in both male and female

Page 11 of 31
groups (Table 2), and resulted in overall male and female average rates of 0.9μg/mL and

1.2μg/mL, respectively. These 2 averages combined resulted in an overall study average of

1.05μg/mL, a rate quite similar to that found by Cunha et al.32 (1.07 ± 0.23 µg/mL) in a

sample of 17 dentate male and female adults elected as controls in a study with chewing

extent limited to 20 masticatory cycles, instead of 15 as fixed in our investigation work.

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As no previous study using Ecaps to determine how extra mastication cycles affect

ME assessment had been carried out, the investigators use Escudeiro et al.’s report 13 (2006)

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on the development of Ecap as a hint. In the referred study, a group of 10 healthy participants

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with nasal respiration, complete dentition, and Class I canine and molar relationship were also

asked to chew on 10mm-long Ecaps for 20 seconds on 3 different occasions. The

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investigators observed that 6 of the subjects performed 1 chewing stroke per minute while the

remaining 4 performed 3 strokes per minute. The analysis of their study data showed that
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those performing 1 stroke per minute (a frequency rate that would result in 20 mastication

cycles if maintained during the 20 seconds of chewing) had an average ME score of 0.4μg/mL
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of fuchsin, whereas the score determined for those performing 3 strokes per minute
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(presumably 60 chewing strokes in 20 seconds) was only 10% higher, 0,44μg/mL.

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Worth pointing out is that 2 previous studies using Ecaps elected length of time (20
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seconds) to limit chewing extent and found levels of ME highly dissimilar from each other as

well as from those herein presented so far. Felicio et al.3 (2008) and Picinato et al.33 (2012)
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reported the following series of concentration of fuchsin released, {0.24; 0.28; 0.31}μg/mL

and {2.50 and 2.57; 2.59; 2.67}μg/mL, with values respectively referring to average ME

scores assessed for chewing “side-unrestrained ”, right-side-only and left-side-only,

respectively. Their study sample comprised healthy individuals with normal occlusion.

It is a fact that our overall ME average (1.05μg/mL) is supported by the report of

Cunha et al.32 (1.07µg/mL). But it is also a fact that in our study male ME average

(0.9μg/mL) is clearly lower than female ME average (1.2μg/mL), despite men’s MBF average

being higher than female’s (630N and 424N,respectively).

Page 12 of 31
 A third fact is that the riddle could be simply solved with the finding that the

Pearson’s correlation test shows neither strong nor moderate correlation between the sets of

MBF and ME rates herein determined (-0.124; -0.088; 0.120; 0.087 – Table 2). However,

seeking support with the latter finding does not prevent the the assumption of measurements

inaccuracy to rise. Therefore, the analysis that follows is of interest for those carrying out

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further investigation using Ecaps to assess ME.

Table 3 shows MBF and corresponding ME determinations for each participant. Only

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26 of the 55 participants showed higher MBF and ME on the same side, suggesting that, in 29

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of the subjects, the impact of MBF did not prevail over that of other factors.

Furthermore, in the each of the 26 individuals with higher MBF and ME on the same

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side, the increase in ME scores as compared with the opposite side does not show the same

proportion of the increase in MBF rates as compared with the opposite side. Moreover, within
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the group of these 26 individuals, no correlation between increases in MBF and in ME was

found (Pearson’s correlation coefficient in male N=14; R=-0.3759; P-Value=0.185314; and in

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female N=12; R=-0.0356; P-Value=0.912538), suggesting that even if MBF impact do prevail
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over the impact of other factors, it varies considerably from individual to individual.
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Once charted, MBF values and ME scores provide a clearer picture of the data under
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analysis. Chart 1 shows MBF values in increasing order aligned with the respective ME

scores. The curves of MBF determined for the right and left side in both male and female
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groups are nearly superimposing, thus providing the visual measure of the finding of no

statistically significant difference between right and left MBF values across both study

groups. Running almost parallel and clearly quite apart, these two sets of nearly coinciding

curves exhibit how similar MBF distribution in men’s sample is to that in women’s . All

curves run within acceptable range of Gaussian distribution. (results of normality testing on

Table 2).

ME scores in both male and female samples also proved to have a nearly normal

distribution, but unlike MBF rates, they produced curves running almost entirely over layered,

Page 13 of 31
though not coinciding. This feature alone suggests very little, if any, impact of MBF on ME.

In fact, Pearson’s correlation test showed neither strong nor moderate correlation between

MBF and ME, at least as assessed in this study, nor the coefficient calculated proved to be

significant. Striking, though, is that MBF curves exhibit considerable slope whereas ME ones

run within ranges showing practically no slope, suggesting that ME was entirely independent

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of the maximal ability to crush food shown by the subjects in our study.

An interesting finding on the relationship between ME and MBF was reported by

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Lepley et al.18. In a study encompassing occlusion, maximum bite force and chewing cycle

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kinematics, the authors concluded that masticatory performance is most closely related to

occlusal factors. Moreover, although a positive relationship between ME and MBF taken

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between canines had been found, the same did not occur with MBF taken between molars.

As MBF measurements were also performed between molars in the present study, the
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odds are that our finding is simply a repetition of Lepley et al.’s. Nevertheless, the strikingly

different behavior of MBF and ME curves as illustrated in Chart 1 urges for investigation into
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the possible contribution of Ecaps internal crushing and grinding mechanics to such behavior
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of MBF and ME curves. Most important is that even if Ecaps are found produce the same
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results that natural hard foods do, knowledge of differences and similarities between natural
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foods and Ecaps regarding chewing will be gained with the research work carried out.

A last finding to clarify is that of female participants having higher ME average as

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compared with male subjects. The first point to observe is that both male and female highest

ME scores are similar (Table 3 and Chart 1). This means that no gender had an indisputable

better ME. On the other hand the male group included the 5 worst Ecaps-chewing performers

whereas the 3 best were in the female group, roughly accounting for male lower and female

higher averages. A brief note is that factors leading to lower ME can go beyond occlusion or

chewing kinematics. . Lepley et all35 found that apart from differences in masticatory

movements, the poorer performers had greater cycle-to-cycle variability than better

performers.

Page 14 of 31
 In conclusion, although the present study has found no relationship between MBF

assessed between molars and ME as determined by using Ecaps, the reported finding should

be investigated further, firstly because a previous research carried out by a team experienced

with the observation of mastication movements and with controlling for other variables

involved in ME has reported a conditional MBF/ME relationship (MBF measured between

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canines). And secondly, because there is still the theoretical possibility that intrinsic features

of Ecaps have contributed to not evidencing a MBF/ME relationship.

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Escudeiro-Santos et al.’s unbreakable PVA capsule is a labor-saving device that would

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make feasible studies that depend on a great number of ME assessments. Besides eliminating

the use of sieves to determine masticatory efficiency, it has the advantage over natural or

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artificial food of not producing crumbles, an inconvenience or even cause of biased

measurement in elderly or individuals bearing dental prosthesis or orthodontic devices.

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However, it is comparative experimentation with this capsule and traditional assessment

methods that will assure the use of Ecaps as accurate alternative method of assessing ME.
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Page 15 of 31
Acknowledgements

Financial support for this study was provided by the Research Support Foundation of

the State of São Paulo (FAPESP), grant no. 2011/19577-0 to the researcher M. D. P. This

independent public foundation had no roles in the design and conduct of the study, including

collection, management, analysis and interpretation of data, preparation, review, and approval

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of the article.

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References

1. Simões WA. Ortopedia funcional dos maxilares vista através da reabilitação neuro-oclusal.

São Paulo: Santos, 1985.

2. Helkimo E, Carlsson GE, Helkimo M. Chewing efficiency and state of dentition. A

t
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methodologic study. Acta Odontol Scand 1978;36(1):33-41.

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performance in young adults and children. Arch Oral Biol 1996;41(1):69-75.

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16.Shiga H, Kobayashi Y, Katsuyama H, Yokoyama M, Arakawa I. Gender difference in

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17. Ikebe K, Matsuda KI, Kagawa R, Enoki K, Yoshida M, Maeda Y, et al. Association of
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masticatory performance with age, gender, number of teeth, occlusal force and salivary
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32. Cunha TR, Della Vecchia MP, Regis RR, Ribeiro AB, Muglia VA, Mestriner W Jr, et al.

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35. Lepley C, Throckmorton G, Parker S, Buschang PH. Masticatory performance and

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chewing cycle kinematics-are they related? Angle Orthod 2010;80(2):295-301.
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TABLE 1 – The very small number (8) of participants declaring to have a preferred chewing 

side – compared with the number (47) of those declaring no preference – did not allow the 
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application of statistics test to analyze chewing side preference as a variable impacting 
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masticatory efficiency.  
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TABLE 2 – Sample size, mean, standard deviation and standard error to maximum bite force 

and fuchsin concentration determined on the right and left sides in male and female groups 

are shown. The 8 sets of data – herein indicated by their calculated means – had normal 

distribution (Kolmogorov‐Smirnov test). Corresponding sets for right and left sides within 

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male and female groups had no statistically significant difference (p< .05). However, 

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statistically significant difference (p<.05) was found when comparing corresponding male 

and female data sets. No correlation between maximum bite force and corresponding 

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concentration of fuchsing was found whether analyzing the coefficient of correlation (r) or 

level of significance (p) determined. 

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TABLE 3 – The analysis of side showing greater maximum bite force and greater masticatory 

efficiency (ME) – measured as the concentration of fuchsin liberated by chewing on the 

unbreakable capsule – in each study participant shows a general discrepancy between these 

two variables. No steady correlation between increased maximum bite force and increased 

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ME could be determined. In some case, increased ME was determined on the opposite side 

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to that showing increased maximum bite force. 

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CHART 1 – Values of maximum bite force (MBF) and fuchsin concentration determined on 

the right and left sides in the 27 male and 28 female participants are plotted in increasing 

order of magnitude. Both men and women show similar rates of maximum bite force on the 

right and left sides. The distribution of MBF showed the same increasing pattern in both 

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groups with men achieving higher levels as compared with women. Despite the increasing 

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distribution of MBF rates, the rates fuchsin concentration indicative of masticatory efficiency 

seems to oscillate about a steady level. Some of the male participants showed levels of 

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fuchsin concentration similar to the top levels determined in women. Some male 

participants also showed the lowest levels of fuchsin concentration, suggesting that female 

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participants formed a more consistent group regarding masticatory performance as 
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compared with the male counterparts. 

 
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Table 1 - General characteristics of the study participants.

Variables n %

Gender

Women 28 50.9

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Men 27 49.1

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Ethnicity

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White 49 89.1

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Non-white 6 10.9

Chewing side preference

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Right side 6 10.9
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Left side 2 3.6

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No preference 47 85.5
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TABLE 2 

            

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Male   Male   Female  Female  Male  Male  Female  Female 
           Maximum  Maximum  Maximum  Maximum  Fuchsin  Fuchsin  Fuchsin  Fuchsin 
Bite Force  Bite Force  Bite Force  Bite Force  Concentr.  Concentr.  Concentr.  Concentr. 
    
right side  left side  right side  left side  right side  left side  right side  left side 

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               [N]  [N]  [N]  [N]  [μg/Ml]  [μg/Ml]  [μg/Ml]  [μg/Ml] 

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    SAMPLE SIZE  27  27  28  28  27  27  28  28 

    MEAN  632.0  627.2  427.2  420.2  0.9  0.9  1.2  1.2 

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    STANDADR DEVIATION  174.1  170.0  139.7  111.4  0.24  0.24  0.16  0.15 

    STANDARD ERROR  33.5  32.7  26.4  21.0  0.05  0.05  0.03  0.03 

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KOLMOGOROV‐SMIRNOV TEST   KCALCULATED  0.113*  0.146 *  0.118*  0.112 *  0.092 *  0.070 *  0.114 *  0.086 * 
* normal distrbution  KCRITICAL  0.254  0.254  0.254  0.254  0.254  0.254  0.254  0.254 
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        SKEWNESS 0.115  0.463  0.430  ‐0.098  ‐0.354  ‐0.331  ‐0.617  ‐0.245 

            KURTOSIS 0.207  ‐0.180  0.641  0.165  0.007  0.563  0.432  ‐0.435 

FCRIT=  4.02  FA=  0.011  (A)*  (A)*             

** statistically different 
ANOVA (p<0.05) 
* not different 
statistically   

FCRIT=  4.02  FB=  0.042      (B)*  (B)*         

FCRIT=  3.93  FC=  52.40  (C)**  (C)**         

FCRIT=  4.02  FD=  0.190           (D)*  (D)*     

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  FCRIT=  4.02  FE=  0.687              (E)*  (E)* 

FCRIT=  3.93  FF=  56.295          (F)**  (F)** 

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rG=  ‐0.124  pG=  0.538  (G)**        (G)**       
** not correlated 

rH=  ‐0.088  pH=  0.662    (H)**        (H)**     

CORRELATION  
COEFFICIENT 

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rI=  0.120  pI=  0.544      (I)**        (I)**   

rJ=  0.087  pJ=  0.659        (J)**        (J)** 

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TABLE 3 

                   

MALE PARTICPANTS  FEMALE PARTICIPANTS 

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MALE  MALE  IDENTIFICATION  MALE  MALE  FEMALE  FEMALE  FEMALE  FEMALE 

IDENTIFICATION 
HIGHER  HIGHER  HIGHER  HIGHER  HIGHER  HIGHER  HIGHER  HIGHER 

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ME ON  MBF ON  MBF ON  ME ON  ME ON  MBF ON  MBF ON  ME ON 
RIGHT  RIGHT  LEFT  LEFT  RIGHT  RIGHT  LEFT  LEFT 
SIDE  SIDE  SIDE  SIDE  SIDE  SIDE  SIDE  SIDE 

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14%  5%  M01  ...  ...  8%  ...  F01  10%  ... 

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27%  ...  M02  1%  ...  ...  ...  F02  41%  9% 

17%  ...  M03  39%  ...  14%  7%  F03  ...  ... 
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34%  17%  M04  ...  ...  6%  9%  F04  ...  ... 

1%  12%  M05  ...  ...  27%  ...  F05  56%  ... 
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19%  9%  M06  ...  ...  30%  19%  F06  ...  ... 
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...  27%  M07  ...  46%  ...  2%  F07  ...  12% 

88%  1%  M08  ...  ...  ...  63%  F08  ...  5% 
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22%  10%  M09  ...  ...  ...  ...  F09  7%  18% 
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2%  ...  M10  1%  ...  ...  16%  F10  ...  1% 

21%  ...  M11  4%  ...  ...  ...  F11  6%  2% 
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...  ...  M12  51%  14%  ...  8%  F12  ...  ... 

...  ...  M13  18%  5%  ...  ...  F13  18%  36% 

...  5%  M14  ...  8%  ...  2%  F14  ...  11% 

...  ...  M15  42%  11%  24%  ...  F15  1%  ... 

...  7%  M16  ...  1%  ...  ...  F16  46%  10% 

...  ...  M17  16%  31%  ...  ...  F17  5%  15% 

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10%  ...  M18  1%  ...  ...  ...  F18  4%  17% 

40%  ...  M19  1%  ...  ...  37%  F19  ...  3% 

...  5%  M20  ...  43%  9%  ...  F20  23%  ... 

...  ...  M21  5%  36%  ...  44%  F21  ...  3% 

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13%  9%  M22  ...  ...  ...  ...  F22  2%  1% 

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4%  35%  M23  ...  ...  ...  11%  F23  ...  4% 

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...  31%  M24  ...  5%  ...  8%  F24  ...  10% 

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4%  7%  M25  ...  ...  ...  ...  F25  12%  34% 

...  7%  M26  ...  3%  ...  31%  F26  ...  22% 

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3%  ...  M27  10%  ...  ...  ...  F27  16%  9% 

               8%  ...  F28  10%  ... 

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CHART 1 

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HIGHLIGHTS FOR REVIEW

Assessing masticatory efficiency is traditionally performed sieving natural hard food chewed.

Sometimes, even more than one sieve is used. Unbreakable PVA capsules containing beads

(Ecaps) with dye incorporated in their composition was developed by Escudeiro-Santos team as

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an alternative method to assess ME. This alternative method eliminates sieving, thus, saving

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considerable work and time. In the present study, Ecaps were tested for its ability to evidence the

relationship between maximal bite force and masticatory efficiency.

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Figure 1

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