archives of oral biology 56 (2011) 991–996

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Association of masticatory performance with age, gender,

number of teeth, occlusal force and salivary flow in Japanese
older adults: Is ageing a risk factor for masticatory
dysfunction?

Kazunori Ikebe *, Ken-ichi Matsuda, Ryosuke Kagawa, Kaori Enoki,

Minoru Yoshida, Yoshinobu Maeda, Takashi Nokubi
Department of Prosthodontics and Oral Rehabilitation, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka Suita, Osaka 565-0871,
Japan

article info abstract

Article history: Objective: In general, ageing is a risk factor for sensory and motor deterioration, with the rate
Accepted 26 March 2011 of decline varying amongst individuals. Concerning masticatory function, missing teeth
along with oral disease seem to accelerate the dysfunction. Here, we aimed to confirm
Keywords: whether masticatory dysfunction by ageing is inevitable. This study investigated the effect
Masticatory performance of age, gender, number of natural teeth, occlusal force and salivary flow on the masticatory
Ageing performance in a large sample of elderly adults.
Number of residual teeth Design: The study sample consisted of 1288 independently living people aged 60–84 years.
Occlusal force Masticatory performance was determined by the comminuted particles of test food. Bilat-
Salivary flow eral maximal occlusal force in the intercuspal position was measured with pressure
Geriatric dentistry sensitive sheets. Stimulated whole saliva was collected.
Multiple regression analysis Results: Masticatory performance was significantly correlated to age, number of residual
teeth, occlusal force and stimulated salivary flow rate by Pearson’s correlation test. The
multiple linear regression analysis showed that, with other variables controlled, mastica-
tory performance was significantly associated with the number of residual teeth (b = 0.456,
P < 0.001), occlusal force (b = 0.244, P < 0.001) and stimulated salivary flow rate (b = 0.069,
P = 0.003). Age was not related to masticatory performance (b = 0.007, P = 0.753).
Conclusions: Declines in the number of residual teeth, occlusal force and salivary flow were
associated with a reduction of masticatory performance in older adults. If tooth loss is not
considered as an attribute of physiological ageing, then ageing by itself may not be a risk
factor for masticatory dysfunction.
# 2011 Elsevier Ltd. All rights reserved.

1. Introduction may be different from other ageing changes because of a

In general, ageing is a risk factor for sensory and motor
deterioration.1 We reach our optimum physiology in our 20 s,
maintain this peak for a few years and gradually decline, with
the rate of decline varying amongst individuals. Oral function
remarkable change in tooth loss.
Masticatory function may be commonly affected in older
adults. Indeed, it is reported that the number of cycles needed
to chew a standard piece of food increases progressively with
age, with increased particle size reduction and longer chewing

* Corresponding author. Tel.: +81 6 6879 2956; fax: +81 6 6879 2957.
E-mail address: ikebe@dent.osaka-u.ac.jp (K. Ikebe).
0003–9969/$ – see front matter # 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.archoralbio.2011.03.019
992 archives of oral biology 56 (2011) 991–996
sequence duration.2,3 Although previous studies4–6 did not
focus on the elderly or included a small sample size, they have
suggested, however, that age per se is not necessarily
associated with a loss of masticatory performance. Factors
reported to affect masticatory performance include loss and
restoration of posterior teeth,4,6–8 occlusal force,5,6,9 salivary
flow,10–12 and oral motor function,13 which seem to accelerate
dysfunction with ageing. Therefore, it is necessary to study
factors that may be linked to the ageing process. We have
previously reported that a decline of posterior occlusal
contacts, occlusal force and hyposalivation appear to be
associated with masticatory performance in 300 older
adults.14
Here we hypothesized that tooth loss, as well as reduced
occlusal force and/or hyposalivation, are associated with a
decline of masticatory performance regardless of ageing or
replacement by prostheses. To test this hypothesis, a cross-
sectional study using a multiple variable regression analysis
was conducted in a larger sample of independently living older
adults.
2. Methods
The subjects were participants of the Senior Citizens’ College
of Osaka prefecture, and were community-dwelling, indepen-
dently living elderly people over the age of 60 years.15 An oral
health lecture was given to the participants, and at the end,
the purpose and procedures of this study were explained to
the audience. Volunteers for this study were solicited to return
for a dental examination on another day. The final volunteer
study population participated in the dental, as well as in the
oral, examination. The population comprised 1288 individuals
(640 men and 648 women) with a mean age of 66.2 (from 60 to
84, SD: 4.2) years. The protocol of this study was approved by
the Institutional Review Board of Osaka University Graduate
School of Dentistry (no. H14-7). All participants gave written
informed consent.
The dental examinations were conducted by five calibrated
dentists. Measurements of masticatory performance, occlusal
force and stimulated salivary flow rate were taken. Individuals
having a partially or fully edentulous arch without a
replacement were excluded from the study participants. As
a result, all of the remaining study participants with a loss of
teeth used a removable denture, and all of their occlusal
contacts were recovered. Participants who wore removable
prostheses kept their dentures in place during all measure-
ments.
2.1. Maximal occlusal force
Bilateral maximal occlusal force was measured with pressure-
sensitive sheets, 97 mm in thickness (Dental Prescale 50H R
type, Fuji Film Co., Tokyo, Japan).15,16 The subjects performed
maximal clenching in the intercuspal position with a sheet
placed between the maxillary and mandibular dental arch.
Subjects with removable partial dentures kept their removable
dentures in place during the measurement of the maximal bite
force. Bilateral bite sheets were selected, because unilateral
bite elements placed in the first molar region frequently
dislodge removable dentures before a maximal bite force can
be reached.17
Bite force was calculated by colour development using
pressure-sensitive film with special analytical equipment
(Occluzer FPD703, Fuji Film Co., Tokyo, Japan). Shiga et al.
showed that the bite force measured with this system had a
significant positive correlation with real pressure values
(R = 0.990, P < 0.01), displaying 98–100% of the true values
for pressures of 20–80 N on 1 mm.18
2.2. Masticatory performance
Masticatory performance was determined by the concentra-
tion of dissolved glucose obtained from test gummy jellies,
which are the standardized food developed for measuring
masticatory performance.19 The subjects were instructed to
chew a gummy jelly using 30 chewing strokes on their
preferred chewing side (left, right or both) and to expectorate
the bolus of comminuted particles as thoroughly as possible.
The collected particles of the comminuted jelly were rinsed
with running water for more than 30 s to obtain an accurate
value. If any adherent glucose remained after mastication, the
surface area might be overestimated.
The particles were then soaked in 15 mL of distilled water
and stirred. The supernatant fluid of the solution was
sampled, and the concentration of dissolved glucose from
the comminuted gummy jelly was measured with a portable
blood glucose metre (Glutest, Sanwa chemical Laboratory Co.,
Nagoya, Japan).20 A linear regression analysis showed that the
concentration of glucose had a significantly high correlation to
the surface area (mm2) of the comminuted jelly (R = 0.993,
P < 0.01). The masticatory performance was assessed by
calculating the surface area of the particles (mm2) from the
glucose concentration, using linear regression.
2.3. Stimulated salivary flow rate
Stimulated whole saliva was collected by the mastication
method. The subjects were asked to swallow all the saliva in
their mouths, chew a measured amount of paraffin wax (Orion
Diagnostica, Finland) for 2 min at their own pace and then spit
into a graduated tube.21 All saliva specimens were collected
between 10:00 am and 3:00 pm. After collection, the volume of
saliva sample was determined gravimetrically, assuming a
specific gravity of 1.0. Flow rates of whole saliva were
expressed as mL/min.
2.4. Data analysis
Data analyses were done using the SPSS Version 14.0 for
Windows (SPSS, Inc., Chicago, USA). Pearson correlations were
performed to determine the association between each vari-
able. Partial correlations were used to assess this relationship
whilst controlling for age.
A multiple linear regression analysis was carried out to test
the relationship of each explanatory variable with the
outcome variable (masticatory performance) after controlling
for the other factors. With explanatory variable, age, number
of residual teeth, occlusal force and salivary flow rate were
used as continuous variables. Gender had only two categories
 archives of oral biology 56 (2011) 991–996 993

Table 1 – Pearson’s correlation coefficient amongst masticatory performance, age, number of residual teeth, occlusal force
and stimulated salivary flow rate.
Age Number of residual teeth Occlusal force Salivary flow rate
Masticatory performance
R 0.197 0.568 0.425 0.103
P-value <0.001 <0.001 <0.001 <0.001
Age
R 0.319 0.183 0.001
P-value <0.001 <0.001 0.995
Number of residual teeth
R 0.394 0.028
P-value <0.001 0.316
Occlusal force
R 0.108
P-value <0.001
Salivary flow rate
R
P-value
R signifies a Pearson correlation coefficient.

and was scored as female = 0, male = 1. All the explanatory
variables were entered into the model. Variance inflation
factors (VIF) for each of the explanatory variables in the
regression model were calculated to test for the presence of
highly correlated explanatory variables.
P values  0.05 were considered to be statistically significant.
3. Results
The mean values and standard deviations of residual teeth,
occlusal force, masticatory performance assessed by calculat-
ing the surface area of the particles and stimulated salivary
flow rate were, 22.7 (7.7) teeth, 491 (296) N, 2339 (841) mm2 and
1.33 (0.97) mL/min, respectively. Participants having a natural
dentition, wearing a removable partial denture and a complete
denture at least one jaw were, 55.8%, 35.0%, 9.2%, respectively.
Masticatory performance was significantly correlated to
age, number of residual teeth, occlusal force and stimulated
salivary flow rate by Pearson’s correlation test (Table 1).
Although age had significantly negative correlations to the
number of residual teeth and occlusal force by a bivariate
analysis, statistically significant partial correlations were
found between masticatory performance and the number of
residual teeth and occlusal force whilst controlling for age
(Table 2). A significant relationship was found between
masticatory performance and stimulated salivary flow rate
(P < 0.001), but variations in salivary flow had only a small
influence on masticatory performance (R = 0.101).
The multiple linear regression analysis showed that
masticatory performance was significantly associated with
the number of number of residual teeth (b: standardized
partial regression coefficient = 0.456, P < 0.001), occlusal force
(b = 0.244, P < 0.001) and stimulated salivary flow rate
(b = 0.069, P = 0.003) (Table 3). Age was not related to
masticatory performance (b = 0.007, P = 0.753).
4. Discussion
Mastication is considered to be the first step for proper
digestion and absorption of nutrients. It is reported that

Table 2 – Partial correlations amongst masticatory performance, number of residual teeth, occlusal force and stimulated
salivary flow rate controlling for age.
Number of residual teeth Occlusal force Salivary flow rate
Masticatory performance
R 0.541 0.402 0.101
P-value <0.001 <0.001 <0.001
Number of residual teeth
R 0.362 0.028
P-value <0.001 0.321
Occlusal force
R 0.115
P-value <0.001
Salivary flow rate
R
P-value
R signifies a partial correlation coefficient.
Control variable: age.
994 archives of oral biology 56 (2011) 991–996
Table 3 – Multiple linear regression analysis for masticatory performance.
Independent variable B SE
Age 1.49 4.73
Gender 63.80 39.11
Number of residual teeth 49.73 2.77
Occlusal force 29.61 3.03
Salivary flow rate 138.34 46.30
Dependent variable: masticatory performance.
B signifies an unstandardized partial regression coefficient.
b signifies a standardized partial regression coefficient, which indicates the relative importance of each variable.
Multiple R = 0.619, R2 = 0.383, P < 0.001.
Age, number of residual teeth, occlusal force and salivary flow rate were used as continuous variables.
Gender: female = 0, male = 1.
community-dwelling older women who use dentures and
have difficulty chewing have a higher risk of malnutrition,
frailty, and mortality.22 This study aimed to confirm whether
masticatory dysfunction by ageing is inevitable or not; in other
words, whether keeping natural teeth or replacement with
removable denture prostheses can prevent masticatory
dysfunction by ageing, as assessed within a large sample of
older adults.
This cross-sectional study evaluated a sample of func-
tionally independent older urban adults who volunteered for
an educational programme. How representative these indi-
viduals are of elderly Japanese is not precisely known.
However, in Japan, most elderly people (95.5% of those 75–
79 years) are functionally independent and have no limita-
tions in their daily activities.23 Therefore, it is important to
understand the oral health of these independent elderly
people who appear to represent a majority of the elderly
Japanese population.
Masticatory performance, which is the ability to break
down foods into discrete portions by chewing to permit
swallowing, is usually assessed by measuring the size of test
food samples that have been chewed for a specific number of
chewing cycles.24 Since 1950,25 fractional sieving with various
natural and artificial foods,26 has been used as a technique of
separating food after chewing to measure masticatory
performance. Previously, we found a positive correlation in
masticatory performance between the present test with
gummy jellies and the sieving method with peanuts (n = 10,
rs = 0.56, P = 0.09). However, it is reported that masticatory
performance values assessed by calculating the area of the
gelatin particles has a wider range than the sieving method.27
Thus, it is possible to differentiate between subjects.
Remaining teeth have been confirmed as key predictors of
the reduction of masticatory performance in an earlier study.6
These results suggest that the preservation of teeth may be of
primary importance for masticatory performance. Although
all of participants with missing teeth wore a partial denture,
the remaining teeth were confirmed as key predictors of the
reduction of masticatory performance. In other words,
replacing missing teeth with a removable prosthesis cannot
approach the efficiency of a complete natural dentition.28
Although the loss of teeth may be compensated for by
dentures, and the dentures contribute to breaking down the
food, our results showed limitations of prosthetic treatments.
In the present study, we evaluated the bilateral occlusal
force in the intercuspal position, which is involved in several
b P value Variance inflation factor
0.007 0.753 1.16
0.038 0.103 1.12
0.456 <0.001 1.32
0.244 <0.001 1.29
0.069 0.003 1.08
critical stages of food breakdown. Whilst it is virtually
impossible to control for occlusal force by gathering matched
individuals, the effects of other factors on masticatory
performance must be measured in a multiple regression
analysis with maximum occlusal force being controlled. It is
not surprising that maximum occlusal force was a strong
contributor to masticatory performance, because this force is
absolutely necessary to comminute food.
Mouth dryness is a common complaint amongst the
elderly and is often associated with diseases and therapeu-
tic medication,29 which suggests hyposalivation is not a
physiological, but rather a pathological, ageing-related
characteristic. The linear regression analysis showed that
the stimulated salivary flow rate also had significant but
weak association with masticatory performance after
controlling for other factors, implying that the salivary flow
rate is linearly associated with masticatory performance.
Xerostomia and other dysfunctions related to salivary
supply may negatively influence the masticatory process
by making it impossible for subjects to gather food into a
bolus before swallowing.28 An experimental study showed
that the masticatory ability of 15 nondysphagic volunteers
aged 22–31 years with natural dentitions was not influenced
by experimental oral dryness.10 A sufficient amount of
saliva is essential for mastication; however, the results of
this study suggest that the amount of salivary flow has only
a small influence on masticatory performance in healthy
older adults.
In fact, as the age of the subject increased, the subjects’
masticatory performance decreased. However, age did not
exert a direct effect on masticatory performance within the
same dentition. This finding suggests that age-related masti-
catory performance need not decline with age if natural
dentition is maintained. The influence of age is currently
viewed as the result of an accumulation of insults to orofacial
structures, as well as function.30
As in other investigations,6,31 gender was not found to
have an effect on masticatory performance. Results of this
study indicate that the occlusal force in females was
significantly lower than in males. Regarding mastication,
females might compensate for their low muscle strength
by increased coordination of other motor and sensory
functions.
In conclusion, missing teeth, decline in occlusal force and
hyposalivation appear to be associated with a reduction of
masticatory performance with ageing in older adults, regard-
 archives of oral biology 56 (2011) 991–996
less of tooth replacement. If tooth loss and hyposalivation are
not considered as characteristics of physiological ageing,
ageing by itself may not be a risk factor for masticatory
dysfunction. With increasing age, maintaining an adequate
number of healthy natural teeth is the best guarantee to
maintain adequate masticatory ability. In the future, longitu-
dinal studies are needed to confirm the causal relationships
and refine this model.
Funding
This research was supported by a Grant-in-Aid for Scientific
Research (no. 19390496, principal grant holder: Kazunori
Ikebe and no. 22592148, principal grant holder: Minoru
Yoshida) from the Japan Society for the Promotion of
Science.
Conflict of interest statement
None declared.
Ethical approval
The protocol of this study was approved by the Institutional
Review Board of Osaka University Graduate School of
Dentistry (no. H14-7).
Acknowledgments
The authors thank Yutaka Kano, D., Engineering, Professor,
Division of Informatics and Mathematical Science, Osaka
University Graduate School of Engineering Science for advice
in the statistical analysis. We are grateful to Masaki
Yoshinaka, Mikiko Amemiya, Yasushi Shimanuki, Fukuko
Nokubi, Taiji Ogawa, Ken Ishida, Sayaka Tada for data
collection. We greatly appreciate the grammatical correction
of the manuscript by Joanne Madsen, M.A.
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