DR.

YOHEI HAMA (Orcid ID : 0000-0001-7949-8726)

Accepted Article
Article type : Original Article

Title: Masticatory performance-related factors in preschool children: Establishing a method to assess

masticatory performance in preschool children using colour-changeable chewing gum

Running head: Masticatory performance in preschool children

Type of article: Original research

Authors: Yohei Hama1, Akemi Hosoda2, Yuriko Komagamine1, Sachi Gotoh3, Chieko Kubota4,

Manabu Kanazawa1, Shunsuke Minakuchi1

Affiliations:

1
Gerodontology and Oral rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo

Medical and Dental University, Tokyo, Japan.

2
Division of Medical Nutrition, Faculty of Healthcare, Tokyo Healthcare University, Tokyo, Japan.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/joor.12553

This article is protected by copyright. All rights reserved.

 3
Pediatric Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental
Accepted Article
University, Tokyo, Japan.

4
National Institute of Public Health, Tokyo, Japan

Correspondence to: Dr. Y. Komagamine

Gerodontology and Oral Rehabilitation

Department of Gerontology and Gerodontology

Graduate School of Medical and Dental Sciences

Tokyo Medical and Dental University

1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan

E-mail: y.komagamine.gerd@tmd.ac.jp

Abstract

Background: A knowledge gap regarding masticatory performance in preschool children exists, which

in turn delays intervention for preventive care; therefore, a method to easily assess performance is

needed.

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 Objective: To investigate the feasibility of assessing masticatory performance using
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colour-changeable chewing gum, and to investigate masticatory performance-related factors in

preschool children.

Methods: This cross-sectional survey was conducted in two childcare facilities and our laboratory.

First, a one-third quantity of colour-changeable chewing gum was masticated by six adults to assess

the nature and progression of colour changes in this quantity. Then, masticatory performance in 370

children 4 to 6 years of age was assessed using the same quantity of colour-changeable chewing gum

(60 chew strokes). The maximum bite force, body height, weight, age, and number of healthy teeth

were recorded. A t-test was performed to determine whether gum-chewing experience or lack thereof

produced a significant difference in masticatory performance. The Spearman’s rank correlation

coefficient was then determined for masticatory performance assessment values and other factors

solely for children with gum-chewing experience.

Results: Measurements from 259 children were obtained. Children with gum-chewing experience

demonstrated significantly higher assessment values, and were deemed to have been correctly

assessed. A very weak but significant positive correlation was observed only between masticatory

performance and the number of healthy teeth.

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 Conclusions: The masticatory performance of preschool children was easily assessed using
Accepted Article
colour-changeable chewing gum. The assessment values demonstrated significant correlation with the

number of healthy teeth, but not with maximum bite force, body height, weight, or age.

Keywords: Mastication, Child, Bite force, Chewing gum, Colour, Deciduous tooth

Background

Masticatory function plays one of the most important roles in oral health; reports have indicated

1
that masticatory performance is related to nutritional status and quality of life (QOL) in the elderly, and

2
also to the onset of sarcopenia. Oral health, once neglected, can be repaired to some degree using

alternative methods and materials, but not completely cured. It is, therefore, better to prevent than to

treat disorders of oral health from the early stages. Moreover, it has been reported that better

3
masticatory performance is correlated with normal body weight in 8- to 12-year-olds. Another study

reported a functional link between mastication and cognitive function in the growth period in an in vivo

4
animal model. Therefore, dentists need to assess and manage masticatory performance in every

generation of patients. Although many studies have addressed masticatory performance in elementary

3, 5, 6 7-9
school ages and upwards, few studies have examined preschool children. Moreover, even these

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 7,8
studies have had small sample sizes of about 20 children, or investigated the effects of intervention
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9
with chewing training, and much remains unknown about what factors are associated with masticatory

performance in preschool children.

Possible reasons for the paucity of studies on preschool children include the difficulty of having

preschool children understand instructions, the potential failure to obtain participation in the study, and

the challenges of assessing preschool children with conventional methods for assessing masticatory

10,11
performance. Methods for assessing masticatory performance include the sieve method, which

12
has long been used worldwide, and the use of gummy jelly, where chewing causes the sample to fall

apart, although with preschool children, it would likely be difficult to completely recover the sample and

13 14
make an accurate assessment. Some assessment methods make use of wax cubes or wax tablets,

but these are not food products and are not very palatable, so preschool-aged subjects could

potentially refuse to chew them, or might accidentally ingest them.

15-18
We therefore chose to use colour-changeable chewing gum as a method for effectively and

easily assessing masticatory performance in preschool children. This gum is easy to chew, even for

15
edentulous individuals. It tastes good, and stays in one piece rather than breaking apart when

chewed and, can therefore, be regarded to be suitable for use in preschool children.

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 8,9
However, colour-changeable chewing gum has seldom been applied in preschool children,
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and it remains uncertain whether measurement is actually possible and, if it is, what measurement

conditions would be suitable. Suspecting that the conventional quantity of colour-changeable chewing

gum (3 g) would be too large for a pre-schooler’s mouth, we believed that one-third of the conventional

9
quantity (1 g, similar to that used in a previous study ) would be suitable; however, there has been no

examination of how chewing one-third the quantity of gum would affect the change in colour.

Therefore, in the present study, we first assessed a one-third quantity of colour-changeable chewing

gum, masticated by adults, to assess the nature and progression of colour changes in this quantity.

9, 15
From the results of this experiment and previous studies, we investigated applicable conditions for

preschool children and assessed their masticatory performance.

The purpose of the present study was to investigate the applicability of a method using

colour-changeable chewing gum to assess masticatory performance in preschool children, and to

investigate factors associated with masticatory performance in this particular population.

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 Methods
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Colour-changeable chewing gum and the assessment method

The test chewing gum (70 × 20 × 1 mm [3.0 g]) contained xylitol, citric acid, and red, yellow, and

blue dyes that change colour when chewed (Masticatory Performance Evaluating Gum XYLITOL,

Lotte Co., Ltd., Tokyo, Japan). In the present study, a one-third quantity of gum (1 g) was used. The

colour of the chewed gum was determined immediately after chewing, in order to minimize time-related

15
changes in colour. There are two methods for assessing colour: measurement using colourimeter

19
and determination according to colour scale.

Investigation of progressive colour changes associated with chewing the test gum

Colour changes with a one-third quantity of the test gum were investigated in adults. Six

participants (male, 50%) of mean age 28.5 (SD, 2.26) years with natural dentition and without missing

teeth (except for the third molar) participated in this experiment. Applicants with caries, severe

periodontal disease, and clinical signs or symptoms of temporomandibular disorders and salivary

dysfunction were excluded. The participants chewed the gum for 10, 20, 30, 40, 55, 70, 120, and 150

strokes. Three trials of each number of strokes proceeded as follows. The participants rinsed their

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 mouths with water for 15 seconds before chewing the gum on their preferred side at a rate of one
Accepted Article
stroke per second and rested for at least 5 minutes between chewing tasks. One examiner measured

colour changes in the chewed gums using a colourimeter and calculated the ∆E values using following

equation:

( L * −72.3) + ( a *+14.9) + ( b * −33.0)

2 2 2
ΔE =

A nonlinear regression analysis was performed with the number of chewing strokes as the

explanatory variable and ∆E as the objective variable, using the below four-parameter logistic function

as a model formula, and compared with the progression of colour changes with a whole quantity (3 g)

15
of gum determined in a previous study.

k2 − k1
ΔE = k1 +
1+ e 3 ( 4 ) ,
k N −k

where k1, k2, k3, and k4 are parameters and N is the number of chewing strokes.

9, 15
In light of the results from this experiment and previous studies , we considered a

suitable number of chewing strokes in preschool children.

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 Investigation of factors associated with masticatory performance in preschool children
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Participants in this experiment were preschool children, 4 to 6 years of age, whose parents or

guardians gave written consent for them to participate in the study. Participants were recruited from

370 such children attending two childcare facilities in an urban area (Tokyo, Japan). Exclusion criteria

were: difficulty chewing gum because of severe dental caries; periodontal disease; temporomandibular

joint disorder(s), or similar; and allergy to xylitol, which is an ingredient in the gum.

The assessed items were as follows.

Masticatory performance. Masticatory performance was assessed using colour-changeable chewing

gum. Participants were asked to chew on a one-third quantity (1 g) of a packet of colour-changeable

chewing gum with 60 chewing strokes, without limitation on the side they chewed. They were asked to

chew the gum at a constant pace of one stroke per second to minimize differences in chewing

conditions among the participants. To prevent mistakes in the number of chewing strokes, a

metronome, set to a pace of one stroke per second, was used, with multiple measurers confirming that

chewing was performed properly. Chewing was immediately followed by an assessment of the colour

of the chewed gum by the aforementioned colourimeter and colour scale methods. ∆E, which was

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 calculated by colourimeter, was converted to a Masticatory Performance Index applying
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colour-changeable chewing gum (MPIG) with the use of a nonlinear regression equation derived from

the results described below under “Investigation of progressive colour changes associated with

15
chewing the test chewing gum.” A higher MPIG signifies a higher masticatory performance .

Maximum bite force. Maximum bite force was determined by measuring the bite force at maximum

occlusion at the deciduous molars on one side, using an occlusal force meter (GM-10, Nagano Keiki,

Japan).

The number of healthy teeth (number of teeth that are not missing, do not have caries, and have

not been repaired because of caries), gender, body height, weight, and age in days were also

recorded. Each parent or guardian was also surveyed about whether the child in question had previous

gum-chewing experience.

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 Statistical analysis
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Each measured variable was tested for normality using the Shapiro–Wilk test. A t-test and the

Wilcoxon rank sum test were also performed on MPIG and colour scale assessment values to

determine if there were differences due to whether subjects had gum-chewing experience.

Analysis was then performed with only data from the group with gum-chewing experience. MPIG

was tested for equivalence with respect to school grade and gender, using -10 to 10 as the acceptable

range of equivalence. Spearman’s rank correlation coefficient was also determined for MPIG and

maximum bite force, age, body height, weight, and number of healthy teeth.

The level of significance was set to 0.05 for all statistical analyses, which were performed using

JMP 8.0 (SAS Institute, NC, USA).

Results

Investigation of progressive colour changes associated with chewing the test chewing gum

The derived nonlinear regression equation is as follows:

2.97 ×10 7
ΔE = 73.2 −
(
1.16×10 −2 N+1.12×103
1+ e
)

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 Figure 1 shows a plot of the nonlinear regression equation for the one-third quantity of chewing
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gum derived in the present study and the nonlinear regression equation for the whole quantity of gum

15
tested in the previous study.

Distribution of MPIG in preschool children

The parents/guardians of 259 children consented to their children’s participation in the study.

Table 1 summarizes information about the study participants.

The t-test and Wilcoxon rank sum test showed that the group with gum-chewing experience had

significantly higher MPIG and colour scale assessment values than the group without experience.

(Figure 2).

Investigation of factors associated with masticatory performance in preschool children

In the group with gum-chewing experience, the equivalence test with -10 to 10 as the allowable

range showed that gender (p=0.002) and school grade (p=0.0002) were equivalent (Table 2).

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 In the group with gum-chewing experience, MPIG and the number of healthy teeth were (very
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weakly) positively correlated, but there was no significant correlation observed between MPIG and

maximum bite force, age, body height, or weight (Figure 3).

Discussion

This is the first survey, on a scale of hundreds of participants, to assess masticatory

performance in preschool children. We demonstrated the applicability of a method using

colour-changeable chewing gum to assess masticatory performance in preschool children, and to

investigate factors associated with masticatory performance in preschool children. Colour-changeable

chewing gum changes in colour from green to red as it is chewed, making it possible to assess

masticatory performance only by recording the colour after chewing. This ease of assessment has

20 19
even allowed for large-scale investigations and, furthermore, there is a colour scale that enables

the general public (i.e., parents and guardians) to assess masticatory performance. Establishing

colour-changeable chewing gum as a method of assessing masticatory performance in preschool

children would offer a broad range of use and could be a significant development.

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 We first investigated how a one-third quantity of colour-changeable chewing gum changes
Accepted Article
colour as chewing progressed. Results showed that the colour change with a one-third quantity of gum

exhibited a monotonic increase, with the amount of increase gradually decreasing as chewing

15
progressed; this was the same trend observed in the previous study for colour changes with a whole

quantity of gum. This suggests that a one-third quantity of gum can also be applied to the assessment

of masticatory performance in the same manner as the conventional whole quantity of gum. Because

the ∆E for colour-changeable chewing gum is nonlinear relative to the number of chewing strokes, it is

an ordinal scale in terms of masticatory performance assessment value; using the derived nonlinear

regression equation to convert ∆E to the corresponding number of chewing strokes makes it possible

15
to use the assessment value from the one-third quantity of gum as a ratio scale. In the present study,

this converted assessment value is called the MPIG. In light of the results from this experiment and

9, 15
previous studies , we inferred that 60 may be a valid number of chewing strokes for application to

preschool children, and applied this number to assess masticatory performance in preschool children.

With a sample of 259 children, we were able to study a far greater number of subjects than past

7-9
studies that have assessed masticatory performance in preschool children. As shown in Table 1,

there were approximately equal numbers of male and female study participants, and they were

approximately equal in terms of age. During measurement, we encountered no accidental ingestion or

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 other such problems, and we were able to assess masticatory performance in all of the participating
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children. With the assumption of normality for the MPIG in all subjects supported by the Shapiro–Wilk

test, neither a ceiling effect nor a floor effect emerges when the histogram is observed, and the

distribution has a shape that is close to the normal distribution (Figure 2). However, the t-test and

Wilcoxon rank sum test showed that the MPIG and colour scale assessment values for children

without gum-chewing experience were significantly lower than those of the children who did have

gum-chewing experience. Moreover, when the MPIG histogram (Figure 2) for the group without

gum-chewing experience is observed, the area with low assessments can be seen to comprise many

subjects’ data. This result does not signify that children who have not chewed gum before have low

masticatory performance (i.e. some children have high masticatory performance, while others have

low masticatory performance), but allows for the interpretation that because of their lack of

gum-chewing experience, they are unable to chew the colour-changeable chewing gum well, resulting

in an improperly low assessment of masticatory performance.

Next, when the histogram of the group with gum-chewing experience is observed, MPIG and

colour scale assessment values were broadly distributed from high scores to low scores, and the

conditions set forth in the present study, of chewing a one-third quantity of gum with 60 chewing

strokes, are believed to be suitable for assessing masticatory performance in preschool children using

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 colour-changeable chewing gum. Thus, deeming masticatory performance to have been correctly
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addressed only with the group with gum-chewing experience, we conducted further analysis by looking

solely at the group with gum-chewing experience.

A very weak but significant positive correlation was observed between MPIG and the number of

healthy teeth (Figure 3). This scatterplot includes an area where a high number of healthy teeth has a

broad MPIG distribution, from high to low, whereas the area representing a low number of healthy

teeth generally has low MPIG. Because few subjects had a low number of healthy teeth (too few to

reach statistical significance), this result may be accidental. However, this result is acceptable from a

clinical point of view (i.e. masticatory performance is low when the number of healthy teeth is low, but

masticatory performance is not necessarily high when the number of healthy teeth is high).

The equivalency test showed that with respect to gender and school grade, MPIG could be

described as equivalent, with -10 to 10 as the allowable range for MPIG. MPIG did not show a

statistically significant correlation with maximum bite force, age, body height, or weight (Figure 3).

While not statistically significant, visual observation of the scatter plot also suggests no relationship

between MPIG and any of the factors (Figure 3). This suggests that MPIG has no association with

strength and physique and, that at 4 and 5 years of age, a higher age does not necessarily mean an

increase in mean values evaluating masticatory performance. These results are different from those of

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 21,22
previous studies, but they do not necessarily contradict the results of the previous studies. Of
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23
course, foods of different density will require different amounts of muscle activity during chewing ; that

is, hard foods require more intense biting when chewed, while softer foods do not require such intense

biting when chewed. The colour-changeable chewing gum is soft, with a density that allows for ample

chewing even by preschool children, and therefore, factors other than maximum bite force were more

strongly related. It would, therefore, be a mistake to interpret the results of the present study as

meaning that maximum bite force is unrelated to masticatory performance in preschool children. It

should be interpreted that an assessment of masticatory performance in preschool children with

colour-changeable chewing gum is reflective of factors apart from maximum bite force or physique.

The question, then, is what elements of masticatory performance in preschool children are

assessed with colour-changeable chewing gum. The act of chewing properly requires the repeated

use of the teeth to breakdown food. That is, ‘tooth elements’ such as the number of remaining teeth,

6,17,24,25
occlusal contact area, and occlusal morphology are related, as are the ‘strength elements’ of

6,21,22,24
chewing. The ‘motor function elements’ of the mouth have also been regarded as necessary,

such as using the tongue or buccal mucosa to reliably place food on the teeth at a timing that is

16,18
coordinated with masticatory movement performed by the temporomandibular joint. In the present

study, the correlation between MPIG and the number of healthy teeth was significant, but very weak,

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 and elements related to strength were not correlated. Therefore, by a process of elimination, we
Accepted Article
concluded the assessment of masticatory performance with colour-changeable chewing gum to have

strongly favoured the assessment of the ‘motor function’ aspects of the mouth. Compared to ‘tooth

elements’ and ‘strength elements’, motor function during chewing is much more difficult to assess; we

hope that more evidence will be gathered to establish colour-changeable chewing gum as an indicator

of motor function during chewing.

In the present study, we confirmed the applicability of a method using colour-changeable

chewing gum to assess masticatory performance in preschool children with gum-chewing experience.

We identified applicable chewing conditions to use for preschool children from the standpoint of

distribution of evaluation values, and then we will test the reliability of this method under the same

conditions in the near future.

Although the number of healthy teeth, maximum bite force, body height, physique, etc, were

investigated as possible factors related to masticatory performance in preschool children assessed

using colour-changeable chewing gum, relationships with diet or environmental factors, such as home

environment, were not investigated. Moreover, the present study was a cross-sectional survey, and did

not allow for investigation of the development of masticatory performance. A longitudinal survey that

This article is protected by copyright. All rights reserved.

 includes the investigation of environmental factors is warranted, and may clarify what conditions and
Accepted Article
environments enable children to better develop their masticatory performance.

Conclusions

The masticatory performance of preschool children with gum-chewing experience was easily

assessed using colour-changeable chewing gum, with a one-third quantity (1 g) of a packet of the gum

with 60 chewing strokes. MPIG of preschool children was significantly correlated with the number of

healthy teeth, but not with maximum bite force, body height, weight, or age.

Acknowledgements

The authors thank Dr. Atsuko Tamura, paediatric dentist, for assistance in planning the research

approach.

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 The present study was conducted in full accordance with the World Medical Association
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Declaration of Helsinki (version 2013) and approved by the Ethics Committee of Tokyo Medical and

Dental University (#1192). Written consent was provided by the parents or guardians of the

participants.

Funding

This study was partially supported by Lotte Co., Ltd., Tokyo, Japan.

Disclosure

Dr. Hama reports grants and non-financial support from Lotte Co., Ltd, during the conduct of the

study. In addition, Dr. Hama has a patent How to develop a colour scale for colour-changeable

chewing gum with royalties paid to Lotte Co., Ltd and Tokyo Medical and Dental University.

Dr. Komagamine reports grants and non-financial support from Lotte Co., Ltd, during the

conduct of the study. Grants from LOTTE Foundation, outside the submitted work.

Ms. Kubota reports grants and non-financial support from Lotte Co., Ltd, during the conduct of

the study.

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 Dr. Kanazawa reports grants and non-financial support from Lotte Co., Ltd, during the conduct
Accepted Article
of the study. Grants from LOTTE Foundation, outside the submitted work. In addition, Dr. Kanazawa

has a patent How to develop a colour scale for colour-changeable chewing gum with royalties paid to

Lotte Co., Ltd and Tokyo Medical and Dental University.

Dr. Minakuchi reports grants and non-financial support from Lotte Co., Ltd, during the conduct of

the study. Grants from Sony Education Foundation, grants from Kobayashi Pharmaceutical Co., Ltd.,

grants from weltec Co., Ltd., outside the submitted work. In addition, Dr. Minakuchi has a patent How

to develop a colour scale for colour-changeable chewing gum with royalties paid to Lotte Co., Ltd and

Tokyo Medical and Dental University.

The other authors have stated explicitly that there are no conflicts of interest in connection with

this article

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 15. Hama Y, Kanazawa M, Minakuchi S, et al. Properties of a colour-changeable chewing gum used to
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evaluate masticatory performance. J. Prosthodont. Res. 2014; 58: 1-5.

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 Tables
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Table 1. Summary data on sample characteristics

Characteristics Chewing experience of the test gum

With experience Without experience

Number 174 85

Gender
Male (%) 83 (48%) 42 (49%)
Female (%) 91 (52%) 43 (51%)

Class
4–5-year-old (%) 75 (43%) 54 (64%)
5–6-year-old (%) 99 (57%) 31 (36%)

Masticatory performance
MPIG (average, 95% CI) * 60.0 (56.9–62.2) 44.8 (40.1–49.6)
Colour scale (median, interquartile range)* 8 (6–9) 7 (5–8)

* A t-test and a Wilcoxon rank sum test revealed significant differences between “Experienced” and

“Did not experience” group in MPIG and colour scale results.

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Accepted Article
Table 2. Evaluation value of masticatory performance

Characteristics
Masticatory performance

MPIG Colour scale

Gender

Male 58.1 (54.4–61.2) 8 (7–9)

Female 60.6 (57.0–64.2) 8 (7–9)

Class

4–5-year-old (%) 59.5 (55.5–63.5) 8 (7–9)

5–6-year-old (%) 59.3 (55.9–62.7) 8 (7–9)

MPIG: mean (95% CI), colour scale: median (interquartile range).

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Accepted Article
Figure legends

Figure 1. Comparison of colour changes with whole quantity gum and one-third quantity gum.

Plot of nonlinear regression equations of the number of chewing strokes and ∆E as derived in a

15
previous study and the present study. Both show the same trends in colour changes.

Figure 2. Histogram of the MPIG and colour scale assessment values of all subjects (a group with

gum-chewing experience and a group without).

For MPIG, normality was assumed for all on the basis of the Shapiro–Wilk test. Compared to the group

without gum-chewing experience, the group with experience had a distribution that was closer to the

normal distribution.

Figure 3. Correlation of MPIG and various factors in the group with gum-chewing experience.

Only the number of healthy teeth showed a (very weakly positive) significant correlation.

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.