The relationship between the number of foods suitable for intake and comprehensively assessed oral function: A cross-sectional study

doi:10.21203/rs.3.rs-5038210/v1

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The relationship between the number of foods suitable for intake and comprehensively assessed oral function: A cross-sectional study

https://doi.org/10.21203/rs.3.rs-5038210/v1

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Background

With a globally aging population, the relationship between oral function and the risk of long-term care is attracting attention. One method for the subjective assessment of oral function is the use of a questionnaire on the number of foods suitable for intake. Although it is possible that objective oral functions, such as tongue pressure and maximum occlusal force, are associated with the number of foods suitable for intake, this relationship has yet to be investigated. This study aimed to clarify the association between overall oral function and the number of foods suitable for intake.

Methods

Patients aged 65 years or older were recruited from an outpatient dental clinic at Tokyo Medical and Dental University. The number of foods that they could consume was assessed using the food acceptance score. Seven oral function parameters, as defined by the Japanese Society of Gerodontology, were also measured. Age, sex, the number of functional teeth, geriatric depression, cognitive function, and oral health-related quality of life were assessed. Variables for which normality was rejected were transformed into tertiles. Multiple regression analysis was performed with the food acceptance score as the objective variable, and each oral function and other items as explanatory variables.

Results

This study included 201 participants (87 men, 114 women). Multiple regression analysis revealed that the number of functional teeth, geriatric depression, oral-related quality of life, masticatory function, tongue pressure, and swallowing function were significantly associated with food acceptance scores.

Conclusions

Aging

Japanese population

Oral function

Food diversity

An aging population presents several challenges, including a growing disparity between average life expectancy and healthy life expectancy, and an increase in the number of elderly individuals with frailty and inadequate nutrition [1]. These problems must also be addressed from the dental perspective [2]. Recently, the relationship between oral function and the risk of requiring nursing care has attracted attention. Previous studies reported an association between oral function and the need for nursing care. In particular, the associations between maximum occlusal force and the risk of developing frailty [3], tongue pressure and malnutrition [4], and masticatory performance and frailty [5] have been highlighted. Moreover, comprehensive oral function assessments have revealed that oral hypofunction is associated with frailty, sarcopenia, and mild cognitive impairment [6], while oral frailty is associated with overall frailty [7] and malnutrition [8].

One method for the subjective assessment of oral function for an individual is to survey the number of foods suitable for intake [9]. Previous studies reported that foods available for intake are associated with cognitive function [10], frailty severity [11], sarcopenia [12], nutritional status [13], and quality of life [14]. This finding suggests that maintaining a large number of foods suitable for intake in older adults is of great significance. To achieve this, it is necessary to identify the factors associated with the number of foods suitable for intake.

What factors contribute to reducing the number of foods suitable for intake? Previous studies have reported that this was associated with a low number of remaining teeth [15]; the condition of prostheses, such as denture stability [16]; the oral frailty 5-item checklist, which is a comprehensive and subjective assessment of oral function [17, 18]; and masticatory performance [19]. It has been assumed that oral functions, such as tongue pressure and maximum occlusal force, are associated with the number of foods suitable for intake, although this relationship has yet to be investigated. Oral function declines with age [20–22]. Thus, the number of foods suitable for intake may diminish with advanced age due to a reduction in oral function, regardless of the maintenance of teeth and prosthetic appliances in a satisfactory condition.

This study aimed to determine the association between comprehensive oral function and the number of foods suitable for intake.

2.1. Study design

This cross-sectional study utilized data obtained from the same participants as in a previous study by our research group [5].

2.2. Participants

Participants were recruited from an outpatient dental clinic at Tokyo Medical and Dental University Hospital. The inclusion criteria were 65 years of age or older; no current dental treatment except for maintenance, such as oral care and denture adjustment; independence in activities of daily living (ADL), such as voiding, bathing, walking, eating, and dressing; and no history of systemic disorders, such as cerebral infarction or orthopedic diseases.

2.3. The number of foods suitable for intake

The number of foods suitable for intake was assessed using the food acceptance score (FAS) [16, 19]. The FAS includes 20 foods that the participants respond to regarding different masticatory difficulties (grade 1 to grade 5; grade 1 being the most difficult to masticate, followed by grades 2, 3, 4, and 5, in order of decreasing masticatory difficulty) from the following four options: 〇: easy to chew, △: difficult to chew, ×: unable to chew, -: never eaten by preference. Only the answer "〇: easy to chew" was given a score of 5. The total score was used as the evaluation value.

2.4. Oral functions

Seven items were evaluated according to the oral hypofunction criteria proposed in 2018 including oral hygiene, oral moisture, occlusal force, tongue-lip motor function, tongue pressure, masticatory function, and swallowing function [2]. Oral hypofunction was defined as a decline in at least three of the seven oral functions outlined in the criteria.

2.4.1. Oral hygiene

Oral hygiene was evaluated using the tongue coating index (TCI). The tongue surface was divided into nine sections, and the tongue coating in each area was evaluated at three levels (scores of 0, 1, and 2) to determine the percentage of tongue coating. The cut-off value for poor oral hygiene was ≥ 50.

2.4.2 Oral moisture

Oral moisture was measured using an oral moisture meter (Oral Moisture Mucus, Life Co., Ltd.). The sensor was applied to the central area of the tongue dorsum for 5 seconds to determine oral moisture levels. Measurements were triplicated and the median value was used as the evaluation value. The cut-off value for oral dryness was ≤ 27.0.

2.4.3. Occlusal force

The occlusal force was evaluated using a pressure-sensitive sheet (Dental Prescale II, GC Co., Ltd.), an analyzer (Byte force analyzer, GC Co., Ltd.), and a scanner (GT-X830, EPSON Co., Ltd.). The participants were instructed to bite the pressure-sensitive sheet with a thickness of 150 µm for three seconds in maximal intercuspation. The red area was quantified using the analyzer which calculated the maximum occlusal force. The cut-off value for the decrease in occlusal force was ≤ 350 N.

2.4.4. Tongue-lip motor function

Tongue-lip motor function was evaluated using a measuring device designed for this purpose (Kenkou-kun Handy; Takei Kiki Kogyo Co., Ltd.). The participants were required to pronounce the syllables /pa/, /ta/, and /ka/ as rapidly as possible for 5 seconds. The number of syllables produced per second was used to determine the oral diadochokinetic value. The cut-off value for decreased tongue-lip motor function was ≤ 6.0 for any one of the /pa///ta///ka/ oral diadochokinesis values.

2.4.5. Tongue pressure

Tongue pressure was evaluated using a tongue pressure-measuring device (JMS Tongue Pressure Meter TPM-01; JMS Co., Ltd.). A balloon was held at the tip of a disposable probe in the anterior part of the participant's palate and compressed by the tongue. Measurements were performed three times with a rest period (30 seconds) between each attempt to prevent fatigue. The average value was used as the evaluation value. The cut-off value for low tongue pressure was ≤ 30.0 kPa.

2.4.6. Masticatory function

The masticatory function was evaluated using a gummy jelly (Glucolumn, GC Co., Ltd.) and a glucose analyzer (Glucosensor GS-II, GC Co., Ltd.). Each participant was asked to freely chew a gummy jelly for 20 seconds, and then, rinse their mouth with 10 mL of water while the gummy jelly is still their mouths. The gummy jelly, saliva, and water were expelled through a filtration mesh, and the glucose concentration in the filtered solution was subsequently quantified. The cut-off value for masticatory dysfunction was ≤ 100 mg/dL.

2.4.7. Swallowing function

Swallowing function was evaluated using the 10-item Eating Assessment Tool (EAT-10). The EAT-10 consists of a series of 10 questions about swallowing function, which the participants responded to using a 5-point scale. The total score derived from their answers was used to evaluate their swallowing function. The cut-off value for decreased swallowing function was ≥ 3.

2.5. Moderator variable

Age, sex, number of functional teeth, geriatric depression, cognitive function, and oral health-related quality of life were assessed.

2.5.1. Functional teeth

A trained dentist part of the research team determined the number of functional teeth. These were calculated by adding fixed prosthetic devices, such as implants and bridge pontics, to the number of remaining teeth, and excluding root stumps and teeth with a mobility level of three.

2.5.2. Geriatric depression

Geriatric depression was assessed using the Geriatric Depression Scale 5 (GDS-5), and a score of 2 or higher was indicative of depression [23].

2.5.3. Cognitive function

The assessment of cognitive function was evaluated using the Mini-Mental State Examination (MMSE) [24].

2.5.4. Oral-related quality of life

Oral-related quality of life was evaluated using the Oral Health Impact Profile 14 (OHIP-14) [25].

2.6. Statistical analysis

Normality was evaluated for each continuous variable using the Shapiro–Wilk test. Items for which the assumption of normality was rejected were divided into tertiles. Each oral function was evaluated using a binary scale, with normal or decreased function based on the respective cutoff values [2]. A multiple linear regression analysis was conducted using the forced entry method, with the FAS designated as the objective variable, oral function and oral hypofunction as explanatory variables, and the others as moderator variables. Statistical significance was set at 0.05. JMP Pro (version 17.0; SAS Institute Inc., Cary, NC, USA) was used for statistical analysis.

2.7. Ethical considerations

This study was conducted in accordance with the World Medical Association Declaration of Helsinki and approved by the Institutional Review Board of Tokyo Medical and Dental University (Approval number: D2021-043). Each participant was provided a comprehensive briefing and asked to provide written informed consent.

A total of 213 individuals were recruited and 201 participants (87 men and 114 women) were included (Fig. 1). Based on the exclusion criteria, one person requiring assistance and who was not considered independent in ADL was excluded, leaving 200 participants for analysis.

Table 1

shows the median and interquartile ranges for age, sex, and oral function, as well as the percentage of participants classified as having oral hypofunction. Oral hypofunction affected 48 participants (24.0%).
Table 1. Participants characteristics
n = 200		median (25%, 75%)
Age (year)		74.0 (71.0, 79.0)
Sex
	Men	86
	Women	114
Food Acceptance Score		80 (65, 95)
Oral function			decline group rate(%)
	Oral hygiene	5 (3, 7)	14.5
	Oral moisture	29.3 (27.4, 30.8)	18.5
	Occlusal force (N)	484.5 (305.9, 728.7)	27.0
	Tongue-lip motor function (times/s)	6.4 (5.8, 6.8)	41.5
	Tongue pressure (kPa)	31.6 (27.0, 35.4)	39.5
	Masticatory function (mg/dL)	159.0 (120.3, 202.8)	16.0
	Swallowing function	0 (0, 1)	11.0
Oral hypofunction
	Nomal	152
	Decline	48	24.0
The number of functional teeth		23.0 (15.3, 27.0)
GDS-5
	Nomal	175
	Depression	25
MMSE		28.0 (26.0, 29.8)
OHIP-14		6.0 (1.0, 13.8)
Data are presented as median values with 25th and 75th percentiles, and the ratio of binarizations. GDS-5: Geriatric Depression Scale 5, MMSE: Mini-Mental State Examination, OHIP-14: Oral Health Impact Profile 14

Multiple linear regression analysis showed significance at p < 0.001 with an adjusted coefficient of determination of 0.30. Tongue pressure, glucose column, EAT-10, number of functional teeth, and GDS-5 and OHIP-14 scores were significantly associated with the number of foods suitable for intake (Table 2).

Table 2. Multiple regression analysis using the food acceptance score as dependent variable
n = 200		β	95% CI	p-value	VIF
Age (year)
	Q2/3 (72.00–77.67) Ref. Q1/3 (< 72.00)	0.05	[-3.85–8.00]	0.55	1.40
	Q3/3 (77.67–94.00) Ref. Q2/3	-0.03	[-7.31–5.09]	0.71	1.61
Sex
	Women (Ref. men)	0.04	[-1.79–3.37]	0.60	1.23
Oral function Normal (Ref. decleased)
	Oral hygiene	-0.02	[-4.31–2.98]	0.75	1.24
	Oral moisture	0.04	[-2.24–4.49]	0.48	1.29
	Occlusal force	0.04	[-2.51–4.38]	0.53	1.74
	Tongue-lip motor function	0.01	[-2.58–3.04]	0.84	1.44
	Tongue pressure	0.15	[0.29–5.72]	0.03*	1.33
	Masticatory function	0.19	[1.27–9.07]	0.01*	1.54
	Swallowing function	0.17	[1.20–9.50]	0.01*	1.27
	Oral hypofunction	-0.04	[-5.58–3.96]	0.79	3.12
Functional teeth
	Q2/3 (19–26) Ref. Q1/3 (< 19)	0.19	[1.54–14.45]	0.02*	1.71
	Q3/3 (26–32) Ref. Q2/3	0.08	[-3.07–9.21]	0.35	1.66
GDS-5
	Depression Ref. no depression	-0.14	[-15.51 - -1.01]	0.02*	1.08
MMSE
	Q2/3 (26–29) Ref. Q1/3 (< 26)	-0.10	[-11.26–1.99]	0.16	1.40
	Q3/3 (29–30) Ref. Q2/3	-0.06	[-7.74–3.16]	0.43	1.37
OHIP-14
	Q2/3 (2–11) Ref. Q1/3 (< 2)	-0.07	[-9.03–3.21]	0.28	1.41
	Q3/3 (11–31) Ref. Q2/3	-0.21	[-14.66 - -3.05]	<0.01*	1.44
p < 0.05, Statistically significant P values are indicated in bold**. GDS-5: Geriatric Depression Scale 5, MMSE: Mini-Mental State Examination, OHIP-14:Oral Health Impact Profile 14 β:standardized partial regression coefficient, 95% CI: 95% confidence interval, VIF: Variance Inflation Factor. Q1/3: the first 3-quantiles, Q2/3: the second 3-quantiles, Q3/3: the third 3-quantiles

This is the first published study to comprehensively examine the association between objectively assessed oral function and the number of foods suitable for intake. The analysis showed that the number of foods suitable for intake was associated with tongue pressure, swallowing function, geriatric depression, and oral-related quality of life, as well as the number of functional teeth and masticatory function.

Previous studies with participants of similar age to our study reported the prevalence of oral hypofunction in community-dwelling elderly to be approximately 36.9–56.3% [6, 26–28]. In contrast, the prevalence of oral hypofunction in our study was 24%, which is lower than that reported in previous studies. This may be because the participants in this study were patients who visited the university hospital regularly for dental maintenance, suggesting that they may have been more health-conscious than the general elderly population. Therefore, our results should be considered with caution.

In this study, the number of functional teeth, GDS, and MMSE scores, which have been reported to be associated with the number of foods suitable for intake, were selected as moderator variables [10, 15, 29]. We also considered the subjective oral assessment items that may influence the number of foods suitable for intake. Notably, the OHIP-14 score was used as the moderating variable. The multiple linear regression analysis revealed that the number of functional teeth and oral health-related quality of life significantly affected the number of foods suitable for intake in this study. Additionally, the association between the number of functional teeth and the number of foods suitable for intake was consistent with previous research [15]. The OHIP-14 is a comprehensive and subjective oral assessment questionnaire that assesses taste, chewing discomfort, and whether the patient is receiving sufficient food. We observed a significant association between the OHIP-14 score and the number of food items suitable for intake. Moreover, depression was significantly associated with the number of foods suitable for consumption, which is consistent with the findings of previous studies [29].

Even after adjusting for these factors, the masticatory function, tongue pressure, and swallowing function remained as significant factors affecting the number of foods suitable for intake. The association between masticatory function and the number of ingestible foods determined in this study is consistent with the results of previous research [19]. Although this was a cross-sectional study and causal relationships could not be imputed, the results may be attributed to the inability to eat hard foods due to decreased masticatory function.

The tongue plays an important role in food intake by cooperating with other oral tissues during mastication. Soft foods that do not require teeth to bite apart. Instead, food masses are formed by the tongue as it presses against the palate to crush the soft food and then, transporting the food masses during the oral feeding and swallowing stages [30]. Patients with severe tongue dysfunction due to tongue cancer and other causes have worse masticatory function and nutritional status than those with mild dysfunction [31]. In a cohort study, patients treated for tongue and floor cancer had fewer remaining teeth, chewing ability, and food intake [32]. Thus, a reduced tongue function affects the choice of food suitable for intake, which is consistent with our results.

Finally, the swallowing function was significantly associated with the number of foods suitable for intake. The swallowing function was assessed using the EAT-10, a self-administered questionnaire. No previous study has examined the relationship between swallowing function as assessed using the EAT-10 and the number of foods suitable for intake. A high EAT-10 score indicates that the patient has many problems with swallowing. In these cases, the FAS response scores tend to be lower.

This study has several limitations. First, this was a cross-sectional study, and as such a causal relationship between the number of foods suitable for intake and each oral function cannot be determined. A longitudinal study is required to clarify this relationship. Second, this study included patients who regularly visited for dental maintenance. It is possible that they may be more health-conscious about oral function than the general population. This should be considered when interpreting our results. Finally, although multiple linear regression analysis was significant for the entire model, the adjusted coefficient of determination was 0.30, suggesting that other factors related to food suitability may be involved. Although not evaluated in this study, food preferences, attitudes, and eating behaviors may have influenced the FAS. Future longitudinal studies with a wider range of participants that considered additional items, such as food preferences and attitudes, are warranted.

This study showed that the number of foods suitable for intake was independently associated with tongue pressure, masticatory function, swallowing function, the number of functional teeth, geriatric depression, and oral health-related quality of life. Further studies are required to clarify whether maintaining high oral function contributes to a greater number of foods suitable for intake.

ADL

activities of daily living

FAS

Food acceptance score

EAT-10

10-item Eating Assessment Tool

GDS-5

Geriatric Depression Scale 5

MMSE

Mini-Mental State Examination

OHIP-14

Oral Health Impact Profile 14

standardized partial regression coefficient, 95% CI:95% confidence interval, VIF:Variance Inflation Factor

Ethics approval and consent to participate

This study was conducted in accordance with the World Medical Association Declaration of Helsinki and was approved by the Institutional Review Board of Tokyo Medical and Dental University (Approval number: D2021-043). Each participant was provided a comprehensive briefing and asked to provide written informed consent.

Consent for publication

Not applicable.

Availability of data and materials

The data supporting the findings of this study are available from Yohei Hama upon request.  

Competing interests

The authors declare that they have no conflicts of interest.

Funding

This research was funded by the JSPS KAKENHI (grant number JP21K09996) and Lotte Research Promotion Grant 2022. The sponsor had no role in the study design; collection, analysis, and data interpretation; writing of the report; or the publication process.

Authors’ contributions

Conceptualization, Y. H. Methodology, Y. H., M. O., and R. F. Formal analysis, Y. H., Y. S., and R. F. Investigation, Y. H., R. F., M. O., and M. M. Resources, Y. H., R. F., M. O., M. M., K. N., and K. Y. Data curation, Y. H., M. O., R. F., and L. X. Writing—original draft preparation, R. F. Writing—review and editing, Y. H. Visualization, R. F. Supervision, M. K. Project administration, Y. H. Funding acquisition, Y. H. All authors have read and agreed to the published version of the manuscript.

Acknowledgments

We would like to thank Editage (www.editage.jp) for English language editing.

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No competing interests reported.

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The relationship between the number of foods suitable for intake and comprehensively assessed oral function: A cross-sectional study

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Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

1. Background

2. Methods

2.1. Study design

2.2. Participants

2.3. The number of foods suitable for intake

2.4. Oral functions

2.4.1. Oral hygiene

2.4.2 Oral moisture

2.4.3. Occlusal force

2.4.4. Tongue-lip motor function

2.4.5. Tongue pressure

2.4.6. Masticatory function

2.4.7. Swallowing function

2.5. Moderator variable

2.5.1. Functional teeth

2.5.2. Geriatric depression

2.5.3. Cognitive function

2.5.4. Oral-related quality of life

2.6. Statistical analysis

2.7. Ethical considerations

3. Results

4. Discussion

5. Conclusion

Abbreviations

Declarations

References

Additional Declarations

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