Abstract
Background
Tongue pressure and occlusal support are associated with the nutritional risk of older adults with dysphagia; however, the combined association of these factors with malnutrition risk remains unexplored. This study aimed to examine the prevalence of malnutrition risk across different combinations of tongue pressure and occlusal support status in older adults with dysphagia.
Methods
We analyzed data from 212 older adults with dysphagia (mean age, 79.1 ± 7.2 years). Malnutrition risk was defined as a Mini Nutritional Assessment Short-Form score of ≤ 11. Low tongue pressure was defined as < 20 kPa, and impaired occlusal support corresponded to an Eichner classification B or C with dentures. Participants were classified into four groups based on tongue pressure and occlusal support status. Multivariable logistic regression was used to examine the association between tongue pressure, occlusal support, and malnutrition risk.
Results
Overall, 59.4% of the participants were at risk of malnutrition. In the individual factor model, low tongue pressure was significantly associated with malnutrition risk (odds ratio [OR] = 3.11, 95% confidence interval [CI]: 1.71 to 5.74). In the four-group model, compared with participants with normal tongue pressure and normal occlusal support, the odds of malnutrition risk were significantly higher in those with normal tongue pressure and impaired occlusal support (OR = 3.54, 95% CI: 1.27 to 10.99), low tongue pressure and normal occlusal support (OR = 3.92, 95% CI: 2.01 to 7.86), and low tongue pressure and impaired occlusal support (OR = 4.17, 95% CI: 1.54 to 12.72).
Conclusions
Among older adults with dysphagia, low tongue pressure and/or impaired occlusal support were associated with higher odds of malnutrition risk. These findings suggest that both tongue pressure and occlusal support may warrant consideration when assessing malnutrition risk in this population, although prospective studies are needed to clarify the temporal and causal relationships.
Keywords: Dysphagia, Malnutrition, Occlusal support, Tongue pressure
Background
Malnutrition is a serious problem in older adults. It leads to higher medical and long-term care costs and lower quality of life (QOL) [1–3]. Particularly among older adults with dysphagia, malnutrition is often associated with reduced dietary intake, limited social participation, and greater psychological stress [4, 5]. Such individuals often develop frailty and sarcopenia, which may further impair their swallowing function owing to muscle weakness and decreased physical function [6]. Therefore, understanding the factors associated with malnutrition in older adults with dysphagia is important from both individual QOL and broader social perspectives.
Numerous studies have demonstrated an association between oral function, the number of remaining teeth, and nutritional status in older adults [7–9]. Remaining teeth and occlusal support may be important for the initial stages of eating because they contribute to food breakdown during mastication [7]. Furthermore, the maintenance of remaining teeth and the restoration of occlusal support through appropriate prosthetic treatment are associated with better mastication function and nutritional status [8]. Another oral factor relevant to eating is tongue function. The tongue plays a central role in mastication and swallowing, including food bolus formation and transport from the oral cavity to the pharynx. Low tongue pressure is reportedly associated with decreased dietary intake [10, 11], and previous studies have also observed associations between higher tongue pressure and better nutritional status [12, 13]. These findings suggest that occlusal support and tongue function may represent distinct but related oral domains relevant to nutritional status in older adults.
However, the joint association of tongue pressure and occlusal support with malnutrition remains unclear [14], particularly in older adults with dysphagia. In clinically vulnerable older adults with oral intake limitation, structural and functional oral problems may coexist within the same individual. In such cases, examining only a single oral factor may not fully capture the oral conditions associated with malnutrition risk. Examining how different combinations of oral conditions relate to nutritional status is necessary to better understand the oral factors associated with malnutrition in this high-risk population.
This exploratory study examined the association between tongue pressure, occlusal support status, and malnutrition risk in older adults with dysphagia. We explored these associations both as individual factors and in combination across groups defined by tongue pressure and occlusal support status. Understanding these patterns of association may help generate hypotheses for future longitudinal studies and support further research on nutritional management in older adults with dysphagia.
Methods
Study design, setting, and participants
In this cross-sectional study, we analyzed medical record data from consecutive outpatients who visited a specialized dysphagia clinic at a university dental hospital, as well as standardized measurement records collected for research during the study period (January 2014 to December 2018). This clinic evaluates and manages patients with chronic eating and swallowing difficulties in routine clinical practice. This study was approved by the Ethics Committee of Nippon Dental University (approval code: NDU-T2017-41) and was conducted in accordance with the ethical principles of the Declaration of Helsinki. The inclusion criteria were age ≥ 65 years and a score of ≤ 6 on the Functional Oral Intake Scale (FOIS) [15]. Within this specialized clinical setting, FOIS ≤ 6 was used as an operational criterion to identify patients with clinically relevant oral intake limitation. We excluded patients with more than half of their tongue resected because post-resection reconstruction may preclude reliable tongue pressure measurement; those with severe cognitive impairment (MMSE ≤ 10) [16] because severe cognitive impairment may compromise the ability to follow assessment instructions; and those with missing data for the key variables (i.e., tongue pressure or occlusal support assessment). All assessments were performed at the initial visit.
Primary outcome
The primary outcome was malnutrition risk, which was evaluated by registered dietitians using the Mini Nutritional Assessment Short-Form (MNA-SF) [17]. The MNA-SF is a validated screening tool that assesses multiple domains, including appetite, weight loss, mobility, and body mass index (BMI). Malnutrition risk was defined as a total score of ≤ 11 points. BMI was calculated as weight (kg) divided by height (m)2. Body weight was measured using a single scale. BMI was not included in the adjustment variables because it is a component of the MNA-SF score.
Key independent variables (tongue pressure and occlusal support)
For participants who used dentures, both tongue pressure measurement and occlusal support assessment were performed with the dentures in place. Maximum tongue pressure was measured by trained dentists using a tongue pressure measurement device (JMS Co. Ltd., Hiroshima, Japan), which has been validated against the Iowa Oral Performance Instrument (IOPI) [18]. Measurements were taken with the participants in a sitting position. A balloon probe was placed between the tongue and the anterior part of the hard palate, and the participants were instructed to press the balloon against the palate with maximum force. Three measurements were taken at intervals of approximately 30 s, and the highest value was recorded as the maximum tongue pressure (kPa). Low tongue pressure was defined as < 20 kPa based on previous dysphagia-related literature [13, 19]. Occlusal support was evaluated based on functional occlusal status, which was assessed by trained dentists using the Eichner classification [20, 21]. The Eichner classification divides the premolar and molar regions into four occlusal support zones, and each participant was categorized into one of the following three classes: Class A (occlusal contact in all four zones), Class B (partial occlusal contact), and Class C (no occlusal contact). In this study, normal occlusal support was defined as Eichner Class A, whereas impaired occlusal support was defined as Eichner Class B or C.
Based on tongue pressure and occlusal support status, the participants were categorized into the following four groups: Group 1 (normal tongue pressure and normal occlusal support) as the reference group; Group 2 (normal tongue pressure and impaired occlusal support); Group 3 (low tongue pressure and normal occlusal support); and Group 4 (low tongue pressure and impaired occlusal support).
Covariates
The following variables were also collected as covariates: age and sex, the Charlson comorbidity index (CCI) as a severity index of comorbidities [22], the MMSE to evaluate cognitive function [23], and the Barthel Index (BI) to evaluate activities of daily living [24]. All covariates were collected by trained speech-language pathologists.
Statistical analysis
All statistical analyses were performed using R software (R project version 4.4.2), and a p-value < 0.05 (two-sided) was considered statistically significant. Missing values of 2.8–5.7% (MMSE: 5.7%; BI, CCI: 3.3%; MNA-SF score: 2.8%) observed in some variables were imputed using the predictive mean matching method (m = 5), and estimates were pooled using Rubin’s rules. Baseline characteristics are expressed as mean (standard deviation) for continuous variables and n (%) for categorical variables.
Multivariable logistic regression was used to explore the association between oral function variables and malnutrition risk. Covariates were selected based on prior evidence and their clinical relevance to nutritional status in older adults. We conducted two complementary analyses. First, to explore the association between each factor when both were included in the model, we examined an individual factor model, which included tongue pressure and occlusal support as separate variables. We then added an interaction term (tongue pressure × occlusal support) to this model. Second, to examine the combined association patterns, we used a four-group model combining tongue pressure and occlusal support status, with the group with normal values for both serving as a reference. P-values for the four-group model comparisons were corrected using the Holm correction. Sensitivity analyses included (1) an alternative tongue pressure cutoff (30 kPa) [25]; (2) an alternative malnutrition cutoff (MNA-SF ≤ 7) [26]; and (3) a complete case analysis.
Results
A total of 1,864 outpatients were assessed for eligibility. After screening, 344 patients met the inclusion criteria. Of these, 132 were excluded because of resection of more than half of the tongue, severe cognitive impairment, or missing data on tongue pressure or occlusal support, leaving a final analytic sample of 212 participants (Fig. 1). Table 1 shows the overall characteristics of the participants. Based on tongue pressure and occlusal support status, 41.5% of the participants were classified into Group 1, 9.4% into Group 2, 36.8% into Group 3, and 12.3% into Group 4. Table 2 shows the multivariable logistic regression results in the individual factor model. Low tongue pressure was significantly associated with malnutrition risk (OR = 3.11, 95% CI: 1.71 to 5.74, p < 0.001). Occlusal support status and the other covariates were not significantly associated with malnutrition risk. The interaction term between low tongue pressure and impaired occlusal support was not statistically significant (OR = 0.30, 95% CI: 0.06 to 1.39, p = 0.122).
Fig. 1.
Flowchart of participant selection. After screening, 344 patients met the inclusion criteria. Of these, 132 were excluded because of resection of more than half of the tongue (n = 15), severe cognitive impairment (MMSE ≤ 10; n = 27), or missing primary exposure data on tongue pressure or occlusal support (n = 90), leaving 212 patients for the final analysis. Abbreviations: FOIS, Functional Oral Intake Scale; MMSE, Mini-Mental State Examination
Table 1.
Characteristics of study participants
| Variable | Overall (n = 212) |
|---|---|
| Age, years, mean (SD) | 79.1 (7.2) |
| Sex, Female, n (%) | 90 (42.5) |
| BMI, kg/m², mean (SD) | 20.0 (3.1) |
| CCI, n (%) | |
| Low (0 points) | 43 (20.3) |
| Medium (1–2 points) | 144 (67.9) |
| High (≥ 3 points) | 25 (11.8) |
| MMSE, points, mean (SD) | 25.5 (4.6) |
| Barthel Index, points, mean (SD) | 80.8 (24.3) |
| FOIS, n (%) | |
| 1–3, Tube-dependent | 15 (7.1) |
| 4–6, Total oral intake | 197 (92.9) |
| Tongue pressure, kPa, mean (SD) | 21.1 (8.5) |
| ≥ 20 kPa, n (%) | 108 (50.9) |
| < 20 kPa, n (%) | 104 (49.1) |
| Eichner classification, n (%) | |
| Class A (normal occlusal support) | 166 (78.3) |
| Class B (partial occlusal contact) | 31 (14.6) |
| Class C (no occlusal contact) | 15 (7.1) |
| Malnutrition risk (MNA-SF ≤ 11), n (%) | 126 (59.4) |
BMI Body Mass Index, CCI Charlson Comorbidity Index, MMSE Mini-Mental State Examination, MNA-SF Mini Nutritional Assessment Short-Form, FOIS Functional Oral Intake Scale
Table 2.
Associations with malnutrition risk in the individual factor model
| Variable | Adjusted OR (95% CI) | p-value |
|---|---|---|
| Low tongue pressure | 3.11 (1.71 to 5.74) | < 0.001 |
| Impaired occlusal support | 2.04 (0.97 to 4.53) | 0.067 |
| Age (per year) | 1.03 (0.99 to 1.07) | 0.172 |
| Sex (Female vs. Male) | 1.53 (0.83 to 2.87) | 0.175 |
| Barthel Index (per point) | 0.99 (0.98 to 1.01) | 0.402 |
| Charlson Comorbidity Index (per point) | 0.99 (0.74 to 1.30) | 0.917 |
| MMSE (per point) | 0.97 (0.90 to 1.04) | 0.402 |
Multivariable logistic regression model with all variables included simultaneously (n = 212). Low tongue pressure: < 20 kPa; Impaired occlusal support: Eichner Class B or C; MMSE: Mini-Mental State Examination
Table 3 shows the prevalence of malnutrition risk and adjusted associations across the four groups defined by tongue pressure and occlusal support status. In the four-group model combining tongue pressure and occlusal support status (Group 1 as the reference), each of Groups 2–4 showed significantly higher adjusted odds of malnutrition risk than Group 1. Groups 2 and 4 included smaller numbers of participants, and the precision of their estimates was limited. As shown in Table 4, sensitivity analyses indicated broadly similar patterns of associations. However, when the tongue-pressure cutoff was set at 30 kPa, the estimate for Group 2 was imprecise and not statistically significant, whereas Groups 3 and 4 remained significant.
Table 3.
Prevalence of malnutrition risk and associations in the four-group model
| Group | Crude prevalence of Malnutrition Risk, % (95% CI) | Adjusted OR (95% CI) | p-value |
|---|---|---|---|
| 1 | 40.9 (31.2 to 51.4) | Reference | — |
| 2 | 70.0 (48.1 to 85.5) | 3.54 (1.27 to 10.99) | 0.020 |
| 3 | 71.8 (61.0 to 80.6) | 3.92 (2.01 to 7.86) | < 0.001 |
| 4 | 76.9 (57.9 to 89.0) | 4.17 (1.54 to 12.72) | 0.014 |
Crude prevalence is the unadjusted proportion of participants with malnutrition risk within each group. Multivariable logistic regression was adjusted for age, sex, Barthel Index, Charlson Comorbidity Index, and Mini-Mental State Examination (n = 212)
OR odds ratio, CI confidence interval
P-values for comparisons of Groups 2–4 versus Group 1 were adjusted for multiple testing using the Holm correction
Group 1: normal tongue pressure (≥ 20 kPa) and normal occlusal support (Eichner Class A)
Group 2: normal tongue pressure (≥ 20 kPa) and impaired occlusal support (Eichner Class B or C)
Group 3: low tongue pressure (< 20 kPa) and normal occlusal support (Eichner Class A)
Group 4: low tongue pressure (< 20 kPa) and impaired occlusal support (Eichner Class B or C)
Table 4.
Sensitivity analyses
| Analysis | Group | Adjusted OR (95% CI) | p-value |
|---|---|---|---|
| Tongue pressure cutoff 30 kPa | 1 | Reference | — |
| 2 | 3.31 (0.34 to 32.22) | 0.273 | |
| 3 | 4.48 (1.93 to 11.25) | 0.002 | |
| 4 | 7.62 (2.71 to 23.32) | < 0.001 | |
| MNA-SF ≤ 7 points | 1 | Reference | — |
| 2 | 6.17 (1.78 to 21.78) | 0.008 | |
| 3 | 4.01 (1.63 to 10.93) | 0.008 | |
| 4 | 5.91 (1.91 to 19.20) | 0.007 | |
| Complete case analysis | 1 | Reference | — |
| 2 | 3.04 (1.05 to 9.70) | 0.047 | |
| 3 | 3.94 (1.95 to 8.18) | < 0.001 | |
| 4 | 4.24 (1.53 to 13.20) | 0.015 |
All models were multivariable logistic regression models adjusted for age, sex, Barthel Index, Charlson Comorbidity Index, and Mini-Mental State Examination. The models based on the imputed dataset included 212 participants, whereas the complete case analysis included 193 participants
OR odds ratio, CI confidence interval, MNA-SF Mini Nutritional Assessment Short-Form, FOIS Functional Oral Intake Scale
P-values for comparisons of Groups 2–4 versus Group 1 were adjusted for multiple testing using the Holm correction
Group 1: normal tongue pressure (≥ 20 kPa) and normal occlusal support (Eichner Class A)
Group 2: normal tongue pressure (≥ 20 kPa) and impaired occlusal support (Eichner Class B or C)
Group 3: low tongue pressure (< 20 kPa) and normal occlusal support (Eichner Class A)
Group 4: low tongue pressure (< 20 kPa) and impaired occlusal support (Eichner Class B or C)
Discussion
In this cross-sectional study, the four-group model analysis showed that all groups with low tongue pressure and/or impaired occlusal support showed significantly higher adjusted odds of being at risk of malnutrition (MNA-SF ≤ 11) than the reference group. Although the point estimate was numerically highest in Group 4, the confidence intervals for Groups 2–4 overlapped. The overall pattern of odds ratios was similar across sensitivity analyses, but the estimates were less precise for Group 2.
The observed association between low tongue pressure and malnutrition risk may be interpreted in light of the physiological role of the tongue in swallowing. The tongue plays an important role in the formation of the food bolus and its transport from the oral cavity to the pharynx [27, 28]. Previous studies have reported associations between low tongue pressure and decreased dietary intake [10]. This study also found that participants with low tongue pressure had a higher prevalence of malnutrition risk, even when they had normal occlusal support. Although the independent association of occlusal support was not significant, this may partly reflect the fact that the present population comprised older adults with oral intake limitation. In such a population, the association between occlusal support and malnutrition risk may have been attenuated.
The four-group model showed that the prevalence and adjusted probability of malnutrition risk were significantly higher in all impairment groups than in the reference group. The confidence intervals for Groups 2–4 overlapped, and these findings should not be interpreted as evidence of a stepwise increase in risk across the impairment groups. Together, these findings suggest that both tongue function and occlusal support may be relevant factors in the nutritional assessment of patients with dysphagia.
In the four-group model, although the group with coexisting low tongue pressure and impaired occlusal support showed the highest point estimate, the confidence intervals for Groups 2–4 overlapped. However, the interaction term between low tongue pressure and impaired occlusal support was not significant, suggesting a lack of clear evidence for a synergistic association. This pattern may be consistent with shared upstream factors (e.g., sarcopenia [29] or frailty [30]) that influence both oral function and nutritional status; however, these factors were not directly measured in this study. Because of the cross-sectional design, reverse causation cannot be excluded, and higher malnutrition risk may itself contribute to reduced tongue pressure. Overall, concurrent impairment in both occlusal support and tongue pressure domains may be associated with nutritional challenges, but the nature of their combined association and the underlying mechanisms require confirmation in future longitudinal studies.
Numerous studies have examined the associations between nutritional status and oral functions (such as tongue pressure and masticatory ability) or the number of teeth [14, 31, 32]. In contrast, the present study targeted older adults seen in a specialized dysphagia clinic, representing a clinically vulnerable group. This study adds to the existing literature by simultaneously evaluating both occlusal support status and tongue pressure, thereby exploring their combined associations with malnutrition risk. These findings suggest that, in clinical populations with dysphagia, oral factors and nutritional status may be associated in a complex manner that involves both structural and functional aspects of oral function.
Clinically, the present findings suggest that low tongue pressure and/or impaired occlusal support may warrant consideration when assessing malnutrition risk in older adults with dysphagia. While previous studies have examined interventions targeting tongue function [33] and occlusal support [34] individually, future longitudinal and interventional studies could evaluate whether addressing both tongue function and occlusal support is associated with improved nutritional outcomes.
This study had several limitations. First, potential residual confounding by unmeasured upstream factors, including frailty and sarcopenia, cannot be ruled out. These upstream factors may influence both oral function and nutritional status, and the observed associations may partly reflect these shared causes. Second, some eligible patients were excluded because of missing data on primary exposure variables, including tongue pressure and occlusal support. Because these variables were primary exposures and clinically valid imputation was difficult, such exclusions may have introduced selection bias. Third, our assessment of occlusal support using the Eichner classification did not include information on denture quality, fit, or actual usage patterns. We also did not evaluate masticatory performance or occlusal force, which limits our understanding of the functional aspects of occlusal support in this population. Fourth, 15 participants (7.1%) were tube-dependent, and their nutritional management may differ from that of those with total oral intake, which may have affected the observed associations. Fifth, our study population comprised older adults with oral intake limitation who were seeking specialized dysphagia care. Therefore, our findings should be interpreted within this clinical population and may not be generalizable to broader older-adult populations. Sixth, dysphagia was not uniformly confirmed using a standardized diagnostic evaluation in all participants, which may limit the interpretation of our findings. Given these limitations, our findings should be interpreted as exploratory and hypothesis-generating, serving as a basis for future hypothesis testing in longitudinal and interventional studies.
Conclusion
In this cross-sectional study, malnutrition risk varied across groups defined by tongue pressure and occlusal support status. These findings suggest that tongue pressure and occlusal support may both be relevant to malnutrition risk in populations with dysphagia, while the clinical utility of their combined assessment remains uncertain and requires confirmation in future prospective studies.
Acknowledgements
We thank Editage for the English-language editing.
Abbreviations
- BI
Barthel Index
- BMI
Body Mass Index
- CCI
Charlson Comorbidity Index
- CI
Confidence Interval
- FOIS
Functional Oral Intake Scale
- IOPI
Iowa Oral Performance Instrument
- MMSE
Mini-Mental State Examination
- MNA-SF
Mini Nutritional Assessment Short-Form
- OR
Odds Ratio
- QOL
Quality of Life
Authors’ contributions
HF: Conceptualization, data curation, formal analysis, visualization, writing—original draft.YY: Methodology, project administration, writing—review & editing.MO: Investigation, writing—review & editing.TK, FT: Supervision, writing—review & editing.All authors read and approved the final manuscript.
Funding
This study was supported by JSPS KAKENHI (grant number 19K19323).
Data availability
The datasets used and/or analyzed during the current study are not publicly available due to ethical restrictions and participant privacy, but are available from the corresponding author on reasonable request and subject to appropriate approvals.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the Nippon Dental University School of Life Dentistry (approval code: NDU-T2017-41). The committee approved an opt-out method for informed consent; study information was disclosed on the clinic’s website, allowing patients the opportunity to decline participation.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are not publicly available due to ethical restrictions and participant privacy, but are available from the corresponding author on reasonable request and subject to appropriate approvals.