INTRODUCTION

Loss of deciduous teeth before the eruption of permanent teeth is known as premature
loss of the primary teeth. Premature loss is tooth replacement before its natural time and before
permanent teeth are sufficient development for eruption (Cavalcanti et al., 2008; Salzmann,
1966). Etiology of premature tooth loss mostly caused by trauma, periodontal disease,
congenital factors and dental caries (Al-Shahrani et al., 2015; Mehdi et al, 2013).

In research conducted by Harahap (2015) and Cardoso et al. (2005), premature loss
occurs mostly at deciduous molar teeth of lower jaw. Most of case on the lower jaw because of
the potential for deposition of food and more accumulation of plaque at back of the mandible.
This can also caused by difficulties in accessibility of brushing the lower jaw teeth especially
on the lingual surface caused of tongue. The accumulation of saliva in the floor of the mouth
because gravity also causes food and more plaque formation in the lower jaw. In the study of
Ahamed et al. (2012) and Al-Shahrani et al. (2015), premature loss of deciduous molar teeth
occurred mostly at the ages of 8 and 9 years and most in the lower deciduous molar teeth with
an incidence of 16.82% (Ahamed et al., 2012). The Cardoso et al. (2005), loss of deciduous
molar tooth at lower jaw often occurred on both sides (69.1%) and the most common event of
two missing teeth were deciduous first molars (teeth 74 and 84). Tooth loss experienced by a
child can affect the selection of food and disruption of the mastication process (Tureli et al.,
2010). Research by Barbosa et al. (2013), the number of teeth lost then the particle size of the
food test material becomes larger so that the sizes of fine food particles produced is less and
shows a low chewing ability

Low chewing ability is one sign of masticatory dysfunction. Chewing acts as one of the
psychomotor stimuli and can affect the brain function of a child (Sakamoto and Nakata, 2010).
Mummolo et al. (2014), states that mastication has a significant relationship to cognitive
function. Chewing dysfunction due to lost of teeth effect at hippocampus and decreased
memory and learning abilities.

Food hardness variations will affect the mastication process. Food hardness will affect
of neurotransmission and can activate the brain especially at the prefrontal cortex because of
greater blood flow and oxygen towards the brain. The presence of that stimuli can increase
prefrontal cortex of ventral region activity (Onozuka et al., 2003; Kamiya et al., 2009). This has
an impact on improving memory and cognitive functions. According to Kubo et al. (2013),
states that mastication is associated with increased blood flow and oxygen (depending on blood
oxygen levels) especially in the hippocampus and prefrontal cortex regions.
RESEARCH METHODS

Type of this research is observational analytic study with cross sectional appproach.
The sample was male and female aged 8-9 years who study on six elementary schools in
Seloharjo village, Pundong Bantul. Total 60 samples divided into three groups: premature loss
2 deciduous molar teeth of lower jaw, premature loss of 4 deciduous molar teeth of lower jaw
and no premature loss. Samples were taken by purposive sampling method and those who met
the inclusion criteria were taken as samples. The inclusion criteria for the study were male and
female aged 8-9 years who participated in the study, premature loss of two tand four deciduous
teeth of lower jaw in the parallel position and control group are non-premature loss also not
premature loss deciduous teeth on upper jaw. Variable control in this study “the food for
chewing test” is processed chicken meat with three types of hardness, which are fried, burned
and boiled with a weight of 3 grams and 30 times the amount of chewing. Uncontrolled
variable in this study was the length of time that the lower jaw premature tooth loss occurred
and masticatory muscle strength.

The amount of chewing power is determined based on chewing results, namely: the
percentage of food that passes through the filter, according to mesh standards after the food is
chewed to be calculated for certain strokes/chews. Mesh used in this study is mesh measuring
8, 10, 20 The food used for chewing power test is food with three levels of hardness (fried,
burned and boiled). The amount of chewing is 30 times and the chewing power is calculated in
grams. Children's cognitive functions are calculated by neuropsychological standard tests with
Modified Mini Mental State Examination for Children (MMMSEC). The data obtained then
analyzed using the Variance Analysis test to see the effect of premature loss molar teeth of
lower jaw to chewing power and cognitive function of male and female aged 8-9 years in
various levels of food hardness.

RESEARCH RESULT

The selected data from the study then analyzed distribution of normality and
homogeneity. After the prerequisite test, normality and homogeneity test, obtained data is
normally distributed and has a homogeneous variance with a value of p> 0.05. Furthermore,
parametric tests were conducted, Variance Analysis tests to see differences in chewing power
and cognitive function based on the group of premature loss two deciduous molar teeth of
lower jaw, premature loss four deciduous molar teeth of lower jaw and no premature loss,
gender (male and female) and level of food hardness (hard, medium, soft) which can be seen in
table 1 and table 2 below.
Table 1. Average, Standard Deviation and ANOVA Test Results for Chewing Value Based on
Group, Gender and Level of Food Hardness

Mean ± Std.
Food Deviation
Group Gender N F p
Hardness
Chewing Power

Hard 10 0,51 ± 0,07

Male Medium 10 0,44 ± 0,06

Soft 10 0,35 ± 0,04

PL 2 teeth
Hard 10 0,41 ± 0,12

Female Medium 10 0,24 ± 0,10

Soft 10 0,13 ± 0,04

Hard 10 0,46 ± 0,04

Male Medium 10 0,42 ± 0,04

Soft 10 0,28 ± 0,07 2,985 0,021

PL 4 teeth
Hard 10 0,29 ± 0,06

Female Medium 10 0,21 ± 0,05

Soft 10 0,12 ± 0,04

Hard 10 2,13 ± 0,06

Male Medium 10 2,05 ± 0,07

Soft 10 1,85 ± 0,11

no PL
Hard 10 1,91 ± 0,09

Female Medium 10 1,78 ± 0,12

Soft 10 1,75 ± 0,12

In table 1 it can be seen that there are differences in chewing power values in the group
of premature loss 2 deciduous molar teeth of lower jaw, premature loss 4 deciduous molar teeth
of lower jaw and no premature loss, gender (male and female) and food hardness level ( hard,
medium and soft) with a value of p = 0.021 (p <0.05). This shows that the premature loss group
of 2 deciduous molar teeth of lower jaw, premature loss of 4 deciduous molar teeth of lower
jaw and no premature loss, sex and the level of food hardness influence the chewing power.
The biggest chewing power is in the group no premature loss, male sex and hard food level
with chewing power value is 2.13. Then, the next test to see the value of cognitive functions
that can be seen in the table below.

Table 2. Average, Standard Deviation and Anova Test Results of Cognitive Function Value
Based on Group, Gender and Level of Food Hardness

Mean ± Std.
Deviation
Food
Group Gender N F p
Hardness
Cognitive
Function

Hard 10 30,40 ± 1,51

Male Medium 10 27,50 ± 1,27

Soft 10 25,90 ± 1,29

PL 2 teeth
Hard 10 25,90 ± 1,66

Female Medium 10 24,60 ± 1,43

Soft 10 23,50 ± 1,08

Hard 10 23,90 ± 1,37

Male Medium 10 22,60 ± 0,70

Soft 10 22,10 ± 0,32 7,020 0,000

PL 4 teeth
Hard 10 22,70 ± 1,06

Female Medium 10 22,10 ± 0,32

Soft 10 22,00 ± 0,00

Hard 10 35,00 ± 0,94

Male Medium 10 34,00 ± 0,94

Soft 10 33,00 ± 0,94

No PL
Hard 10 34,30 ± 0,82

Female Medium 10 32,60 ± 1,35

Soft 10 29,60 ± 0,70

Table 2 shows that there are differences in cognitive function values in the group of
premature loss 2 deciduous molar teeth of lower jaw, premature loss 4 deciduous molar teeth of
lower jaw and no premature loss, gender (male and female) and level of food hardness (hard,
medium and soft) with a value of p = 0,000 (p <0.05). This shows that the premature loss group
of 2 deciduous molar teeth of lower jaw, premature loss of 4 deciduous molar teeth of lower
jaw and no premature loss, sex and the level of food hardness have an effect on cognitive
function. The biggest effect in cognitive function is in the group no premature loss, male sex
and level of hard food hardness with cognitive function values of 35.00. Post-hoc tests were
performed to see how much influence between premature loss 2 deciduous molar teeth of lower
jaw, premature loss 4 deciduous molar teeth of lower jaw and no premature loss, sex (male and
female) and food hardness level (hard, medium , soft) to chewing power and cognitive
function. In the post-hoc test, it was found that between premature loss groups and no
premature loss, gender (male and female) and the level of food hardness (hard, moderate, soft)
had significant statistical values, so it could be concluded that premature loss 2 teeth deciduous
molar teeth of lower jaw, premature loss of 4 deciduous molar teeth of lower jaw and no
premature loss, sex (male and female) and food hardness (hard, medium, soft) effect on
chewing power and cognitive function.

DISCUSSION

Based on statistical tests there were significant differences in chewing power values in
the premature loss group 2 deciduous molar teeth of lower jaw, premature loss 4 deciduous
molar teeth of lower jaw and no premature loss, gender (male and female) and food hardness
level (hard, medium , soft) with a value (p <0.05). The biggest chewing power is in the group
no premature loss, male sex and hard food level with chewing power value of 2.13.

In groups no premature loss or those who did not experience tooth loss, they showed
value of post-hoc chewing is greater than the group that experiences premature loss. A large
chewing power value indicates that the number of fine food particles produced from chewing
results is more, while a low chewing power value indicates less amount of fine food particles.
This is because children who have premature loss of the deciduous molar teeth of lower jaw
have less chewing power caused by loss of teeth.

Posterior tooth loss immensely affects the activity of mastication. Chewing performance
depends on the number of functioning teeth and the occlusal contact area of the antagonist teeth
which affects bite strength (Orchadson and Cadden, 1998). The large number of posterior teeth
lost, made occlusal contact loss occurs which can affect the decrease in masticatory
performance (Ikebe et al., 2012). Posterior teeth, which are molar teeth, have a masticatory
plain in the form of squiggly teeth that can help in the process of destroying food (Itjingningsih,
2012). This research is also in line with research conducted by Barbosa et al. (2013), that the
number of teeth lost make the particle size of the food test material is greater so that the number
of sizes of fine food particles that produced is less and shows a low chewing ability.

A large chewing power value is shown in male (table 1). Male have more chewing
power than female. This research is in line with Garner and Kotwal (1973) who stated that male
tend to have stronger chewing power than female. Male have more activity than female so they
need more nutrition and food consumption. This causes muscle mastication to become more
active and stronger in male. The size of the teeth of male is also greater than women so that the
teeth are stronger. This makes the masticatory power of male stronger than female so that the
mastication muscles of male have more number of contractions of fibers (Garner and Kotwal,
1973).

A large chewing power value is also shown in the level of hardness food . Gaviao et al.
(2006), states that chewing power efficiency can be influenced by the food hardness. A child
who is often eating hard and high-fiber foods will have greater chewing power than children
who often eat soft foods. This is also in line with the research of Narwidina (2016). According
to research conducted by Narwidina (2016), the choice of food hardness, the value of food
hardness and gender can affect chewing power. In this study it was found that food hardness
can increase children's chewing power.

Based on statistical tests (table 2), there were significant differences in the value of
cognitive function in the premature loss group 2 deciduous molar teeth of lower jaw, premature
loss 4 deciduous molar teeth of lower jaw and no premature loss, gender (male and female) and
level of hardness food (hard, medium, soft) with a value (p <0.05). The biggest cognitive
function is in the group no premature loss, male sex and level of food hardness with cognitive
function values of 35.00.

In the group no premature loss showed a higher cognitive function value than the group
that experienced premature loss 2 deciduous molar teeth of lower jaw and premature loss 4
deciduous molar teeth of lower jaw. The value of cognitive function is greater in the group no
premature loss because the masticatory function is better than the group that has premature
loss. According to Mummolo et al. (2014), states that mastication has a significant relationship
to cognitive function. In groups no premature loss has a cognitive function value greater than
the group of children who have premature loss. This is due to the presence of masticatory
activity stimuli that capable of improving cognitive function in the hippocampus area, which is
an important area of the brain in the process of learning and memory (Kubo et al., 2013).
Chewing acts as one of the psychomotor stimuli that can affect the brain function (Sakamoto
and Nakata, 2010). Masticatory dysfunction due to tooth loss can affect the hippocampus and
decrease of memory and learning abilities (Mummolo et al., 2014).

In line with the research conducted by Sakamoto and Nakata (2010) that reduced
masticatory activity stimulus in children can be a risk factor for decreased thinking ability,
spatial awareness and memory (cognitive function) and inhibited growth and development of
neurons in the hippocampus morphologically and functionally. In the study of Ono et al.
(2010), states that active mastication can increase the activity of the hippocampus and
prefrontal cortex, which are the most important areas in cognitive processing. According to
Kubo et al. (2013), states that mastication is closely related to increased blood flow and oxygen
(blood oxygen level dependent), especially in the hippocampus and prefrontal cortex areas. The
loss of deciduous or permanent molars caused by premature loss can reduce the ability of
chewing power so that it can affect the reduction of learning ability and memory (Onozuka et
al., 2003).

A large value of cognitive function is shown in male sex. Male have more activity than
female so they need more nutrition and food consumption. This causes muscle mastication to
become more active and stronger in male (Garner and Kotwal, 1973). Muscle activity can
affect chewing power efficiency. The presence of masticatory power derived from the
contraction of nerve muscle fibers in large male can lead to blood flow and oxygen present in
the area around the prefrontal cortex, which can improve cognitive function (Takahashi et al.,
2007).

The large value of cognitive function is indicated by the hard level of food hardness
rather than the level of moderate and soft food hardness. This is in line with the research of
Narwidina (2016). According to a study conducted by Narwidina (2016), the value of food
hardness can affect children's chewing and cognitive function. In this study it was found that
food hardness can increase chewing ability and cognitive function from children. Hard food
will affect neurotransmission which can help activate the brain, especially in the prefrontal
cortex because of increased blood flow and oxygen activity towards the brain (Onozuka et al.,
2003; Kamiya et al., 2009). Increasing flow results in local perfusion and increase higher
oxygen consumption. This has an impact on increasing nerve metabolism in the brain,
especially the prefrontal cortex area, which is the part that plays a role in children's memory
and cognitive functions (Bourne, 1982).

CONCLUSION

1. There is an influence of premature loss of mandibular deciduous molar teeth, gender

and level of food hardness on chewing power.
2. There is an influence of premature loss of mandibular deciduous molar teeth, gender
and level of food hardness on cognitive function.

SUGGESTION

1. In further research it is recommended to do a CT-scan head examination to see the brain

picture of children with premature loss and children who do not have premature loss.
2. In further research it is recommended to use hard and soft food hardness levels as
chewing power test material.
3. In further research it is recommended to measure masticatory muscle strength and
measurement of cognitive function in various tests.
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