journal of prosthodontic research 63 (2019) 31–34

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Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Original article

Tongue function is important for masticatory performance in the

healthy elderly: a cross-sectional survey of community-dwelling
elderly
Keiichiro Sagawaa , Hiroyasu Furuyaa , Yuki Oharac , Mitsuyoshi Yoshidad ,
Hirohiko Hiranoe , Katsuya Iijimaf , Takeshi Kikutania,b,*
a
The Nippon Dental University, Graduate School of Life Dentistry, Division of Clinical Oral Rehabilitation, Tokyo, Japan
b
The Nippon Dental University, Tama Oral Rehabilitation Clinic, Division of Rehabilitation for Speech and Swallowing Disorders, Tokyo, Japan
c
Tokyo Medical and Dental University, Department of Oral Health Care Education, Graduate School of Medical and Dental Sciences, Tokyo, Japan
d
Hiroshima University Graduate School of Biomedical Sciences, Department of Advanced Prosthodontics, Hiroshima, Japan
e
Tokyo Metropolitan Institute of Gerontology, Research Team for Promoting Independence of the Elderly, Tokyo, Japan
f
The University of Tokyo, Institute of Gerontology (IOG), Tokyo, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: The aim of this study was to determine the influences of oral motor function such as tongue
Received 7 May 2016 function and bite force on masticatory performance in the elderly.
Received in revised form 7 February 2018 Methods: We randomly selected 245 subjects who has 28 natural teeth among community-dwelling
Accepted 26 March 2018
elderly. We evaluated masticatory performance using a gummy jelly, and also measured bite force,
Available online 7 September 2018
tongue muscle force, and the speed of tongue movement.
Results: We found that reduced masticatory performance to be associated with decreased the speed of
Keywords:
tongue movement and/or tongue muscle force, indicating that reduced oral motor function also
Elderly
Oral function
influences masticatory performance.
Masticatory function Conclusions: These results suggest that keeping oral motor function, as well as maintenance of occlusal
Tongue muscle force support, to be important for maintaining masticatory function in the elderly.
Speed of tongue movement © 2018 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.
Bite force

1. Introduction masticatory performance is affected by not only the number of

Aging is rapidly progressing in Japan as well as all over the
developed country. Recently, much concern has been paid to
sarcopenia and frailty for extending healthy life expectancy.
Nutrition is one of the key factors for preventing such conditions.
Maintaining good masticatory function is considered to promote
balanced nutrient intake [1], resulting in good nutritional
condition and contributing to healthy longevity. Previous studies
identified a significant relationship between masticatory perfor-
mance and the number of remaining teeth [2,3]. These studies
enhanced the importance of maintenance of the remaining teeth
for adequate nutrient intake and improvement of life prognosis
[4,5]. Therefore, it is not too much to say that maintaining the
number of remaining teeth by preventing dental disease is
essential for the elderly to live a healthy life [6]. However,
remaining teeth but also oral motor function [7]. Oral motor
function such as jaw and tongue movement is decreased with
aging [8], and impaired by several medical conditions such as
cerebrovascular disease and neurodegenerative disorders [9,10].
Therefore, we have to evaluate the oral function as well as tooth
loss for the prevention of masticatory performance in the elderly
population. However, there have been few reports on the
association between diminished oral motor function and a
reduction in masticatory function [7,11]. The aim of this study
was to determine the influences of oral motor function such as
tongue function and bite force on masticatory performance in the
elderly.
2. Materials and methods
2.1. Participants

* Corresponding author at: The Nippon Dental University, Tama Oral Rehabilita- This study was conducted as a part of Kashiwa project [12]. In
tion Clinic, Division of Rehabilitation for Speech and Swallowing Disorders, 4-44-19 2012, a total of 12,000 community-dwelling, functionally inde-
Higashi-cho, Koganei-City, Tokyo 184-0011, Japan. pendent adults aged 65 years or older were randomly drawn from
E-mail address: kikutani@tokyo.ndu.ac.jp (T. Kikutani).

https://doi.org/10.1016/j.jpor.2018.03.006
1883-1958/ © 2018 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.
32 K. Sagawa et al. / journal of prosthodontic research 63 (2019) 31–34
the resident register of Kashiwa city, a commuter town for Tokyo in
Chiba prefecture, Japan, and asked by mail to participate in the
study. A total of 2044 older adults (1013 men, 1031 women) agreed
to participate in the study and comprised the inception cohort.
From their oral examination, 245 persons (116 men and 129
women; mean age, 70.7 4.0 years, range 65–87), whose occlusion
up to the second molar was kept with natural teeth enrolled in this
study. This study was approved by the Ethics Committee of Nippon
Dental University (NDU-T2014-05).
2.2. Evaluations
2.2.1. Masticatory performance
Masticatory performance was measured by the gummy jelly
method, as reported by Shiga et al. [13]. Each subject was asked to
sit on a chair at rest and asked to chew gummy jelly on their
habitual chewing side for 20 s. After chewing, the subjects were
asked to hold 10 ml of distilled water in their mouths for a moment
and to spit into a cup. The cup containing the gummy jelly and the
saliva was then filtered, and the filtrate was collected. For the
evaluation of masticatory performance, the glucose concentration
in the filtrate was measured as glucose extraction by means of a
glucose testing device (GS-1; Fujita, Tokyo, Japan).
2.2.2. Bite force
Bite force, tongue muscle force and the speed of tongue
movement were measured for evaluating oral motor function. Bite
force, represented by the strength of the masticatory muscles, was
assessed with the maximum clenching intensity over a 3-s period,
which was measured using a pressure-sensitive sheet (Dental
Prescale 50 H, Type R; Fujifilm Corp., Tokyo, Japan) and analyzed
with a scanner (Occluzer FPD-703; Fujifilm) [14].
2.2.3. Tongue muscle force
Tongue muscle force, represented by the maximum tongue
pressure, was measured by the method reported by Hayashi et al.
[15] using a hand-held balloon probe and a manometer (JM-TPM;
JMS Co., Ltd., Hiroshima, Japan). The subjects were asked to
compress the balloon onto their palates for approximately 7 s by
maximum voluntary effort of the tongue.
The mean peak values for the three records were defined as
tongue muscle force.
2.2.4. The speed of tongue movement
The speed of tongue movement was assessed by oral
diadochokinesis, which was performed using a commercially
available measuring apparatus (Kenko-kun; Takei Scientific Instru-
ments Co., Ltd., Niigata, Japan). The subjects were asked to
pronounce “ta” sounds for 5 s as quickly as possible. The number of
“ta” sounds uttered during a 1-s period was used for this analysis
[16,17].
2.2.5. Skeletal muscle mass
Skeletal muscle mass was evaluated by Bioelectrical impedance
analysis method with Body Composition Analyzer (InBody 430,
Table 1. Comparisons of masticatory performance and oral motor function between men and women.
Item Men (n = 116)
Mean (SD)
Age 70.4 (3.9)
SMI (kg/m2) 7.5 (0.6)
Masticatory performance (mg/dl) 259.2 (100.9)
Bite force (N) 934.6 (375.2)
Tongue muscle force (kPa) 31.8 (6.6)
Speed of tongue movement (syllables/s) 6.3 (0.9)
Inbody, Seoul, Korea) [18]. Appendicular skeletal muscle mass
(ASM) was derived as the sum of the muscle masses of the four
limbs. ASM was then normalized by height in meters squared to
yield the skeletal muscle mass index (SMI) (kg/m2) [19].
2.2.6. Statistical analysis
The mean value of masticatory performance, bite force, tongue
muscle force, the speed of tongue movement and SMI were
compared between men and women using Mann–Whitney U test.
Correlation among age and these values were analyzed with
Spearman’s rank correlation coefficient for each male and female
subject. Multiple regression analysis was performed to assess the
influences of age and oral motor functions.
PASW statistics 22 software (IBM, Tokyo, Japan) was used for all
statistical analyses. The level of statistical significance was set at
p < 0.05.
3. Results
There was no significant difference in masticatory performance
or the speed of tongue movement between men and women, while
oral motor functions, as represented by bite force, and tongue
muscle force, were found to have significantly higher values in men
than in women (Table 1). Analysis of the relationship between age
and other factors revealed that age was significantly related to the
speed of tongue movement in men and the tongue muscle force in
women (Tables 2 and 3). Based on these results, multiple linear
regression analysis was performed to assess the relationships of
masticatory performance with bite force, tongue muscle force and
the speed of tongue movement, considering age effect. Masticatory
performance was significantly related to the speed of tongue
movement in men, tongue muscle force and the speed of tongue
movement in women (Tables 4 and 5).
4. Discussion
The present study demonstrated that masticatory performance
was significantly related to the speed of tongue movement, and in
women it also related to tongue muscle force. Several previous
studies have shown a significant relationship between masticatory
performance and the number of natural teeth. In the present study,
we were able to examine many elderly persons with 28 natural
teeth for assessment of the relationship between masticatory
performance and oral motor function, by eliminating the influence
of the number of natural teeth. Thus, this study showed, for the
first time, that masticatory performance is related to tongue
muscle force and/or the speed of tongue movement. Skeletal
muscle mass and muscle force are known to differ between
genders [20]. In this study, we further noted significant gender
differences in the SMI, bite force and tongue muscle force, which
prompted us to analyze these factors separately by gender. Tongue
muscle force and bite force differ significantly between the
genders, with the difference in bite force being more evident.
Nevertheless, no significant difference was observed in masticato-
ry performance. A positive correlation has been recognized
Women (n = 129) p Value
Mean (SD)
71.0 (4.0) 0.200
5.8 (0.6) < 0.001
245.7 (85.4) 0.247
679.6 (340.0) < 0.001
29.7 (6.4) 0.014
6.2 (0.9) 0.471
 K. Sagawa et al. / journal of prosthodontic research 63 (2019) 31–34 33

Table 2. Correlations among age, masticatory performance and oral motor function in men.

Item Age SMI Mastication of gummy jelly Bite force (N) Tongue muscle force Speed of tongue movement
Age – 0.050 0.174 0.079 0.022 0.191*
SMI – 0.055 0.094 0.076 0.005
Mastication of gummy jelly – 0.163 0.103 0.200*
Bite force (N) – 0.101 0.035
Tongue muscle force – 0.212*
Speed of tongue movement –
*
p < 0.05.

Table 3. Correlations among age, masticatory performance and oral motor function in women.

Item Age SMI Mastication of gummy jelly Bite force (N) Tongue muscle force Speed of tongue movement
Age – 0.166 0.038 0.081 0.192* 0.081
SMI – 0.040 0.041 0.230** 0.011
Mastication of gummy jelly – 0.201* 0.248** 0.238**
Bite force (N) – 0.191* 0.064
Tongue muscle force – 0.247**
Speed of tongue movement –
*
p < 0.05.
**
p < 0.01.

Table 4. Results of multiple regression analysis in men.

Model Unstandardized coefficient Standardized coefficient t Value p Value 95.0 % CI for B

B Standard error β Lower limit Upper limit

(Constant) 316.880 193.542 1.637 0.104 66.637 700.397
Age 3.424 2.385 0.132 1.436 0.154 8.149 1.302
Bite force (N) 0.041 0.025 0.151 1.656 0.101 0.008 0.089
Tongue muscle force 0.126 1.426 0.008 0.088 0.930 2.700 2.951
Speed of tongue movement 22.358 10.693 0.199 2.091 0.039 1.169 43.547

Dependent variable: masticatory performance.

Table 5. Results of multiple regression analysis in women.

Model Unstandardized coefficient Standardized coefficient t Value p Value 95.0 % CI for B

B Standard error β Lower limit Upper limit

(Constant) 1.905 152.069 0.013 0.990 299.082 302.892
Age 0.484 1.828 0.023 0.265 0.792 3.135 4.103
Bite force (N) 0.031 0.022 0.123 1.407 0.162 0.013 0.074
Tongue muscle force 2.683 1.197 0.200 2.242 0.027 0.315 5.052
Speed of tongue movement 17.513 8.145 0.189 2.150 0.033 1.392 33.634

Dependent variable: masticatory performance.

between masticatory performance evaluated using a gummy jelly
and bite force [21,22]. Shiga et al. noted a significant gender
difference in the masticatory performances of denture-wearing
elderly people, with significantly higher bite force and masticatory
efficiency in men [23]. It may be reasonable to expect that men,
who have higher bite force, also have higher masticatory efficiency.
Nevertheless, no gender difference in masticatory efficiency was
observed among the participants of the present study. This may be
related to the fact that, in this study, we identified tongue pressure
as being a significant factor associated with masticatory perfor-
mance. Tongue pressure has been shown to be significantly
associated with masticatory performance measured by gummy
jelly chewing [24]. The present study also showed a positive
correlation between these two parameters in women. These
results suggest that females compensate for their lower bite force
with tongue muscle force to maintain masticatory performance.
Mastication starts with ingestion of food and finishes with
swallowing a food bolus, requiring various functions including
ingestion, biting, grinding, mixing, food bolus formation, and
swallowing. Since these functions are interrelated and interacting
with each other, there are various challenges associated with
assessing each function objectively and quantitatively. There are
two main methods of measuring masticatory performance:
directly measuring the masticated samples, and an indirect
approach which requires measuring other factors involved in
mastication [2,13,25–27]. The former evaluated the volume of
dissolution of sugar in gum or gummy jelly with mastication, and
the latter evaluated the jaw movement or bite force as masticatory
function. At present, no single method is available for assessing
masticatory performance. In the present study, we used a gummy
jelly to assess masticatory efficiency objectively. Although the
reliability and validity of this method has not been adequately
established as yet, we used this method because it has already been
employed in other studies [13,23], and is generally considered to be
applicable to assessing the multiple functions comprising masti-
cation, including grinding, biting and mixing.
As described above, masticatory performance has been
investigated using various methods, and is reportedly related to
the number of teeth [21] and occlusion [28] as well as bite force
[22].
34 K. Sagawa et al. / journal of prosthodontic research 63 (2019) 31–34
Exercise performance generally involves strength, range, speed/
skill in motion, and durability. The present study assessed tongue
movement strength on the basis of tongue muscle force [15], and
assessed the speed/skill of tongue movement by oral diadocho-
kinesis [17], but did not assess the range of motion or durability,
because no objective method for such measurement has yet been
established. Nevertheless, our study revealed masticatory perfor-
mance to be significantly related to tongue muscle force and/or the
speed of tongue movement, suggesting the importance of the
tongue in mastication. In the process of mastication, the tongue
transfers captured food to the teeth, and further transfers ground
food to the teeth. Through these movements, the tongue mixes the
food with saliva, thereby playing a central role in food bolus
formation. Our results do not clearly show how the tongue is
involved in masticatory movement, but do indicate the necessity of
adding tongue movement to the assessments of masticatory
performance.
Skeletal muscle mass has been well documented to decrease
with age, and this also affects human physical function [29]. A
reduction in physical function affects oral function, and conse-
quently may lead to diminished masticatory function. The present
study, conducted in community-dwelling elderly persons living
independently, showed reduced oral motor function to affect
masticatory function in these relatively healthy elderly persons. On
the other hand, we noted no age-related change in SMI in subjects
in this study, regardless of gender. The fact that all subjects
maintained 28 natural teeth suggests that people who adequately
maintain their natural teeth are more likely to maintain proper
skeletal muscle mass. A study showed that people having at least
20 residual teeth are less likely to become frail than those with an
edentulous jaw [30]. Thus, these results may indicate the potential
role of maintaining natural teeth in the prevention of sarcopenia.
The observed correlation between SMI and tongue muscle force in
females also suggests that, despite their weaker bite force than that
of males, in females the masticatory performance is compensated
for by tongue motor function, which may contribute to the
maintenance of whole-body skeletal muscle mass. Watanabe et al.
described a correlation between reduced tongue motor function
and frailty [31]. We believe this relationship is more closely in frail
and/or sarcopenia elderly. Further studies will be needed to
demonstrate this hypothesis.
5. Conclusion
The present study demonstrated that masticatory performance
is affected by the speed of tongue movement and/or tongue muscle
force. Therefore, maintenance of oral motor function, as well as
occlusal support, is important for the elderly in order to maintain
adequate masticatory function.
Acknowledgements
This study was supported by a Health and Labor Sciences
Research Grant (H24-Choju-Ippan-002) from the Ministry of
Health, Labor, and Welfare of Japan.
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