Chewing ability and its associated factors in maintenance hemodialysis patients: A cross-sectional study

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This study aimed to investigate the current status of chewing ability and its associated factors in Chinese MHD patients. Methods A cross-sectional study was conducted at a tertiary hospital in Chengdu from July to October 2024. Chewing ability was objectively assessed using color-changeable gum, with grades 1–2 defining decreased function. Other variables included general information, anxiety and depression symptoms, nutritional status, and activity of daily life (ADL). Multivariable logistic regression identified the factors influencing chewing ability. Results A total of 154 MHD patients aged ≥ 55 years were included in this study, and the prevalence of decreased chewing ability was 27.3%. Associated factors included: number of remaining teeth < 20 (OR = 4.657, 95%CI: 1.910-11.353), subjective chewing difficulty (OR = 3.399, 95%CI: 1.224–9.438), low articulatory oral motor skills (OR = 3.654, 95%CI: 1.466–9.104), and malnutrition (OR = 4.913, 95%CI: 1.819–13.271) (P < 0.05). Conclusions MHD patients are more likely to have decreased chewing ability than the general population. HD staff can provide comprehensive management based on oral status examinations, self-reports of oral health outcomes, and validated nutritional screenings. oral function chewing ability hemodialysis cross-sectional study Introduction Hemodialysis (HD) is one of the most important renal replacement therapies for end-stage renal disease. By the end of 2023, the number of patients undergoing HD in China had reached approximately 916,000, exhibiting a sustained annual increase. With the development of medical technology, the life expectancy of maintenance hemodialysis (MHD) patients has been extended, which increases the financial burden, the cost of support, and the demand for long-term care. Oral health plays a pivotal role in systemic well-being [ 1 ], recognized by the World Health Assembly in 2021 as a global health priority [ 2 ]. However, the 4th National Oral Health Epidemiology Survey revealed poor oral health conditions among Chinese adults [ 3 ], and dental expenditure was at a lower level than in developed countries [ 4 , 5 ]. Oral disease in adults with HD is very common [ 6 ], but few studies give attention. Chewing is a process that includes predation, crushing and mixing of food, the formation of a bolus, and delivery to the pharynx, which greatly impact food intake [ 7 ]. It can be observed for a comprehensive evaluation of oral function [ 8 ]. Mastication stimulates gut motility and fluid secretion through the cephalic–vagal reflex, aiding digestion and nutrient absorption [ 9 ]. Instead, chewing difficulty causes indigestion and malabsorption [ 10 ]. As the process of indigestion and malnutrition intensifies, it further leads to sarcopenia, frailty, and impaired ADL (activity of daily living) [ 11 – 13 ]. In addition, decreased chewing ability lowers the related quality of life and affects mental health issues such as increasing the incidence of depression [ 14 , 15 ]. Chewing ability is usually assessed by three methods: direct objective, indirect, and subjective assessment [ 16 – 18 ]. There is considerable variation in different assessments. Subjective reports are often influenced by subjects' food avoidance behaviors, personal preferences, nutritional habits, etc., and there is a tendency for overestimation [ 19 ]. In contrast, objective assessments are valid and reliable. Previous studies have shown that the decline in masticatory function is related to gender, age, number of teeth, level of education, etc [ 20 – 22 ]. However, the main study population of these studies was mostly community-dwelling elderly people, and the epidemiological characteristics of decreased masticatory function in the general population may not apply to MHD patients, which deserves to be investigated. Therefore, this study aims to investigate the current status of chewing ability in MHD patients, analyze their influencing factors, and provide reference for the implementation of scientific oral health management by healthcare workers in dialysis units. Methods Study Population This study was a cross-sectional study design and is reported according to the STROBE principle. A cluster sampling method was performed to include MHD patients in a tertiary hospital in Chengdu, from July to October 2024. Inclusion criteria were as follows：(1) aged 55 years or older; (2) regular dialysis 2-3 times per week; (3) voluntary participation in this study. Patients with the following conditions would be excluded:(1) oral surgery or tooth extraction in the last 1 month; (2) hospitalized; (3) dementia or mental illness. This study was approved by the Institutional Review Board of Sichuan University. All participants were investigated after providing the relevant informed consent. Assessments A color-changeable gum (Masticatory Performance Evaluating Gum XYLITOL, Lotte Co, Ltd., Tokyo, Japan) was used to assess chewing ability. It was distributed to the patients by the researcher, and they were instructed to chew left and right for 30 each, for a total of 1 minute. In order to obtain the actual value, the patients were asked to remove the removable dentures if any were worn. When it was taken out, the researcher assessed the chewing ability according to the color chart comparing the color of chewed gums with a total of 5 color grades, with grade 1 being green and grade 5 being red. Grades 1-2 were classified as “decreased chewing difficulty”, and grades 3-5 were classified as “normal chewing ability”[23, 24]. General information includes age, gender, education, marital status, personal monthly income, and duration of dialysis. Oral health-related information was collected, including the number of remaining teeth, using dental floss, frequency of brushing, and dental cleaning [25]. Subjective chewing difficulty and low articulatory oral motor skills were indicated by a response of “yes” to the self-reported questions: “Do you have any difficulties eating tough foods now compared with 6 months ago?” and “Have you had difficulty in clear pronunciation recently?” [26, 27]. Depression and anxiety symptoms were assessed using the 5-item Geriatric Depression Scale (GDS-5: range 0 to 5) [28] and the 7-item Generalized Anxiety Disorder (GAD-7) (GAD-7: range 0 to 21) [29], respectively. Depressive symptoms were defined as a GDS score ≥2, and anxiety symptoms were defined as a GAD score ≥5. Barthel index (BI) measured the independence and functional ability in ADL (BI score: range 0 to 100) [30]. The original 10-item form of the BI consisted of 10 common ADL activities. Impaired ADL was defined as a BI score <100. Malnutrition was assessed by the Malnutrition-inflammation Score (MIS) [31]. The MIS consists of 4 parts (medical history, physical examination, body mass index, and laboratory values) and 10 components in total (MIS score: range 0 to 10). A higher score reflects a more severe degree of malnutrition and inflammation. An MIS ≥8 was defined as malnutrition. Data Collection Data collection was conducted via the Questionnaire Star platform(www.wjx.cn) using face-to-face interviews. All investigators were HD nursing staff who used a unified guide for data collection. When the patients had unclear questions, they were given guidance in time. Before the formal survey, the purpose, methodology, and significance of the study were explained to the subjects to obtain informed consent and sign the relevant informed consent form. The surveys were all during dialysis. The remaining part of the questionnaire was filled in after the chewing gum test was completed. Each questionnaire required 10-15 minutes to complete. Data Analysis Data analysis was performed using SPSS 26.0 software (IBM Corporation, Armonk, NY, USA). Quantitative data was depicted with frequencies (n) and percentages (%). The Chi-square test was used to analyze the difference groups between normal and decreased chewing ability. Before multivariable analysis, collinearity diagnostics were performed on independent variables. Variables were retained only if they met the following criteria: variance inflation factor (VIF) 0.1. To control confounding bias and determine variables independently associated with chewing ability in the sample, a multivariate logistic regression model (Forward: LR) was performed with selected variables showing a p-value of <0.05 in the univariate analysis. Odds ratios (ORs) and their respective 95% confidential intervals (CIs) were calculated. A p-value <0.05 was considered significant. Results A total of 154 MHD patients were included in this study. Among them, 27.3% of the patients were defined as decreased chewing ability, and 43.5% of them aged over 70 years old. The majority of the patients were male (58.4%). A significant proportion had a college degree or above (44.2%), subjective chewing difficulty (55.8%), and had undergone treatment over 5 years (66.2%). See detail in Table 1 . Univariate analysis with the presence of decreased chewing ability as the dependent variable showed that there were statistical differences between the two groups in terms of age, subjective chewing difficulty, low articulatory oral motor skills, number of remaining teeth, dental floss, depression, malnutrition, and ADL (p 0.591 and the VIF were < 1.693, indicating that there was no significant covariance between the included independent variables for further analysis. Taking whether the MHD patients had decreased chewing ability as the dependent variable, the value of normal chewing ability was 1 and decreased was 2. The results of binary logistic analysis showed that the number of remaining teeth < 20 (OR = 4.657, 95%CI: 1.910-11.353), subjective chewing difficulty (OR = 3.399, 95%CI: 1.224–9.438), low articulatory oral motor skills (OR = 3.654, 95%CI: 1.466–9.104), malnutrition (OR = 4.913, 95%CI: 1.819–13.271) were the influencing factors of chewing ability in MHD patients, as shown in Table 3 . Table 1 General information (n = 154) Variables Categories n(%) Age, years <70 87(56.5) ≥ 70 67(43.5) Gender Male 90(58.4) Female 64(41.6) Education level Primary school and below 24(15.6) Middle school 29(18.8) High school 33(21.4) College degree or above 68(44.2) Married Yes 126(81.8) No 28(18.2) Personal income monthly, yuan <4000 58(37.7) ≥ 4000 96(62.3) Duration of dialysis, years <5 52(33.8) ≥ 5 102(66.2) Subject chewing difficulty No 68(44.2) Yes 86(55.8) Low articulatory oral motor skills No 107(69.5) Yes 47(30.5) Number of remaining teeth <20 54(35.1) ≥ 20 100(64.9) Tooth brushing <2 times per day 58(37.7) ≥ 2 times per day 96(62.3) Dental floss No 79(51.3) Use 75(48.7) Anxiety Yes 24(15.6) No 130(84.4) Depression Yes 47(30.5) No 107(69.5) Malnutrition Yes 32(20.8) No 122(79.2) Impaired ADL No 96(62.3) Yes 58(37.7) Table 2 Comparison and univariate analysis of the chewing ability in MHD patients (n = 154) Variables Normal n = 42 Decreased chewing ability n = 112 χ2 P Age, years 21.576 <0.001 <70 11(26.2) 76(67.9) ≥ 70 31(73.8) 36(32.1) Gender 1.694 0.193 Male 21(50.0) 69(61.6) Female 21(50.0) 43(38.4) Education level 6.192 0.103 Primary school and below 11(26.2) 13(11.6) Middle school 6(14.3) 23(20.5) High school 6(14.3) 27(24.1) College degree or above 19(45.2) 49(43.8) Married 1.229 0.268 Yes 32(76.2) 94(83.9) No 10(23.8) 18(16.1) Personal income monthly, yuan 1.107 0.293 <4000 13(31.0) 45(40.2) ≥ 4000 29(69.0) 67(59.8) Duration of dialysis, years 0.005 0.945 <5 14(33.3) 38(33.9) ≥ 5 28(66.7) 74(66.1) Subject chewing difficulty 17.697 <0.001 No 7(16.7) 61(54.5) Yes 35(83.3) 51(45.5) Low articulatory oral motor skills 22.911 <0.001 No 17(40.5) 90(80.4) Yes 25(59.5) 22(19.6) Number of remaining teeth 25.329 <0.001 <20 28(66.7) 26(23.2) ≥ 20 14(33.3) 86(76.8) Tooth brushing 0.664 0.415 <2 times per day 18(42.9) 40(35.7) ≥ 2 times per day 24(57.1) 72(64.3) Dental floss 9.367 0.002 No 30(71.4) 49(43.8) Use 12(28.6) 63(56.2) Anxiety 0.526 0.468 No 34(81.0) 96(85.7) Yes 8(19.0) 16(14.3) Depression 5.900 0.015 No 23(54.8) 84(75.0) Yes 19(45.2) 28(25.0) Malnutrition 20.987 <0.001 No 23(54.8) 99(88.4) Yes 19(45.2) 13(11.6) Impaired ADL 14.456 <0.001 No 16(38.1) 80(71.4) Yes 26(61.9) 32(28.6) Table 3 Logistic regression analysis of the chewing ability of the MHD patients Variables β SE Wald χ 2 P OR (95%CI) Number of remaining teeth ≥ 20 1.00 (Reference) < 20 1.538 0.455 11.447 0.001 4.657 (1.910−11.353) Subjective chewing difficulty No 1.00 (Reference) Yes 1.224 0.521 5.516 0.019 3.399 (1.224–9.438) Low articulatory oral motor skills NO 1.00 (Reference) Yes 1.296 0.466 7.736 0.005 3.654 (1.466–9.104) Malnutrition No 1.00 (Reference) Yes 1.592 0.507 9.858 0.002 4.913 (1.819–13.271) Constant −3.368 0.533 39.901 <0.001 Discussion This study showed that the prevalence of decreased chewing ability in MHD patients was 27.3%, which was higher than that of the general population (14.1%-20.0%) [ 11 , 22 , 32 ]. Possibly due to the different study populations, MHD patients commonly have impaired salivary gland function, which is directly related to systemic dehydration status and insufficient glandular perfusion, and is often manifested as dry mouth[ 33 ]. Inadequate secretion of saliva, an important lubricant and digestive fluid in the oral cavity, directly affects food moistening, dough formation, and initial digestion, leading to significant discomfort and reduced efficiency during chewing. In addition, inadequate dialysis also leads to disruptions in calcium and phosphorus metabolism, lowering blood calcium levels, which increases the risk of tooth loss in MHD patients [ 34 ]. Recently, oral frailty is commonly used to describe oral health and function. Several studies have shown a high prevalence of oral frailty in MHD patients (45.2%-69.2%) [ 35 – 37 ]. Then, there is a lack of specific assessment tools for oral frailty in MHD patients, and their tools are subjective screening tools, including the assessment of subjective dry mouth, which may lead to a high detection rate and affect the accuracy of the assessment. Then, it has been suggested that chewing difficulties should be included in geriatric syndromes as a comprehensive assessment of oral function [ 38 ]. Color-changeable gum has been confirmed its validity and is widely used in the assessment of chewing ability in older people [ 16 , 23 ]. Therefore, the objective chewing ability assessment method used in our current study is considered to give more reasonable epidemiologic data on the oral status of MHD patients. This study shows that the number of remaining teeth is a key factor affecting chewing ability, which is consistent with previous studies [ 12 , 20 , 22 ]. The World Health Organization set 20 teeth as the maintenance of normal chewing ability [ 39 ]. Reduced number of teeth directly affects the chewing ability of MHD patients, especially the loss of posterior teeth [ 40 , 41 ]. Periodontal tissue lesions in HD patients are characterized by early onset and high progression, which are significantly higher than those in the general population. The mean number of natural teeth of HD in this study was 19.76, which was lower than the average (24) of the 4th National Oral Health Epidemiology Survey in China [ 42 ]. Patients undergoing MHD exhibit not only increased incidences of gingival bleeding and swelling, but also progressive manifestations of severe periodontopathies, including gingival recession, root exposure, periodontal suppuration, and accelerated alveolar bone resorption [ 43 ]. Destruction of periodontal supportive tissues directly leads to decreased tooth stability, making it impossible for patients to grind food effectively during chewing due to loose teeth, especially fibrous foods or foods that require greater bite force. In addition, the required routine visits for dialysis sessions can make it difficult for HD patients to reserve time to visit dentists for check-ups or treatment, which makes it difficult for MHD patients to maintain good oral health [ 35 ]. It suggests that healthcare providers in HD units should pay attention to the oral status of MHD patients and incorporate it into the whole management system, and should carry out restorative treatment in time for patients with the number of remaining teeth < 20. In this study, we found that MHD patients with subjective chewing difficulties were more likely to have decreased chewing ability. Self-assessed health status is a reflection of an individual's overall perception of their current health status. Individuals' subjective perceptions may appear earlier than disease manifestations and can provide important health information for potential risk groups [ 44 ]. Self-reports of chewing difficulties still have good predictive value, although a tendency towards overestimation has been noted. Martin et al. [ 45 ] view self-assessed health status as an important tool for understanding an individual's health status and reflecting changes in the individual's health trajectory. Clinical practice should prioritize enhancing self-awareness of oral health status among MHD patients. Implementing dynamic self-assessment protocols enables the timely detection of oral health deterioration. HD healthcare providers and family caregivers can utilize these self-reported outcomes to initiate evidence-based screenings and targeted interventions, thereby preventing or mitigating the decline of chewing ability. In the present study, low articulatory oral motor skills were found to be an influential factor in chewing ability, which is similar to the results of the previous study [ 46 ]. Mastication constitutes a complex sensorimotor process reliant on coordinated neuromuscular activity among orofacial structures. In MHD patients, accumulated guanidine compounds inflict neurotoxic damage to the trigeminal motor nuclei and facial nerve branches governing lip and tongue movement, thereby impairing the synchronized contraction of masticatory and articulatory muscle groups [ 47 ]. In addition, MHD patients are often affected by the disease with social withdrawal, reduced verbal communication, and a corresponding decrease in muscle strength, resulting in poor chewing ability. Some rehabilitation exercises are necessary. Evidence suggests that some oral exercises can be performed to improve chewing ability in community-dwelling older adults [ 48 – 50 ], but further studies are needed in dialysis populations. Malnutrition is significantly associated with decreased chewing ability in MHD patients. Protein-energy wasting (PEW) is more common in MHD patients due to nutrient loss on dialysis, increasing the risk of sarcopenia and frailty [ 51 ]. Prolonged protein loss leads to decreased muscle mass and muscle strength, including a range of oral muscle groups such as the tongue and masticatory muscles, which negatively affects chewing ability [ 52 , 53 ]. In turn, MHD patients with decreased chewing ability often have inadequate food intake and reduced food variety, further exacerbating malnutrition and establishing a bidirectional deterioration cycle [ 54 , 55 ]. MHD patients should undergo quarterly nutritional risk screening, implement dietary optimization with texture-modified foods and targeted nutrient supplementation, maintain rigorous oral hygiene, and initiate preventive masticatory exercises to mitigate functional decline and improve systemic health outcomes. This study had several limitations. First, this study was a single-center design with a limited sample size. This may impact the generalizability of the study. Second, causality cannot be firmly established due to the cross-sectional study design. Finally, some potential influencing factors were not included, such as uremic toxin quantification and vitamin D deficiency. Future studies should also incorporate multicenter longitudinal studies to establish causal relationships between the prevalence of chewing ability and various factors in MHD patients. Conclusions This study revealed a prevalence of decreased chewing ability was 27.3% in MHD patients, and number of remaining teeth, subjective chewing difficulty, low articulatory oral motor skills, and malnutrition were the factors associated with chewing ability. Color-changeable gum can be used for early detection of chewing function in MHD patients. These findings suggested that healthcare providers should be attentive to the oral status of patients with MHD, to self-reported outcomes, and to timely completion of nutritional screenings. Declarations A cknowledgements We would like to thank all staff members and participants of the study. F unding This work was supported by Natural Science Foundation of Sichuan Province [Grant Number: 2024NSFSC1607]. C onflict of interest statement The authors declare they have no conflicts of interest. Author contributions Lin Chen and Sikai Tang designed the study. Li Yang and Lijuan Liu collected the data. Sikai Tang and Qiuyan Zhao participated in checking the data and performed the statistical analysis. Lijuan Liu and Sikai Tang draft the manuscript. All authors read and approved the final manuscript. Clinical trial number Not applicable. Ethics approval and consent to participate The design and implementation of the present study were conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of West China Hospital of Sichuan University. All participants were investigated after providing the relevant informed consent. References Baiju RM, Peter E, Varghese NO, Sivaram R: Oral Health and Quality of Life: Current Concepts . Journal of clinical and diagnostic research : JCDR 2017, 11 (6):Ze21-ze26. Zupo R, Castellana F, De Nucci S, Dibello V, Lozupone M, Giannelli G, De Pergola G, Panza F, Sardone R, Boeing H: Beverages Consumption and Oral Health in the Aging Population: A Systematic Review . 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Strippoli GF, Palmer SC, Ruospo M, Natale P, Saglimbene V, Craig JC, Pellegrini F, Petruzzi M, De Benedittis M, Ford P et al : Oral disease in adults treated with hemodialysis: prevalence, predictors, and association with mortality and adverse cardiovascular events: the rationale and design of the ORAL Diseases in hemodialysis (ORAL-D) study, a prospective, multinational, longitudinal, observational, cohort study . BMC nephrology 2013, 14 :90. Oftedal S, Rayward AT, Fenton S, Duncan MJ: Sleep, diet, activity, and incident poor self-rated health: A population-based cohort study . Health psychology : official journal of the Division of Health Psychology, American Psychological Association 2021, 40 (4):252-262. Martin CM: Self-rated health: patterns in the journeys of patients with multi-morbidity and frailty . Journal of evaluation in clinical practice 2014, 20 (6):1010-1016. Kato Y, Kikutani T, Sagawa K, Tamura F: Association between masticatory movement and oral and physical function in healthy older women . Journal of prosthodontic research 2022, 66 (3):416-421. Wang K, Liu Q, Tang M, Qi G, Qiu C, Huang Y, Yu W, Wang W, Sun H, Ni X et al : Chronic kidney disease-induced muscle atrophy: Molecular mechanisms and promising therapies . Biochemical pharmacology 2023, 208 :115407. Kim HJ, Lee JY, Lee ES, Jung HJ, Ahn HJ, Jung HI, Kim BI: Simple oral exercise with chewing gum for improving oral function in older adults . Aging clinical and experimental research 2021, 33 (4):1023-1031. Kim HJ, Lee JY, Lee ES, Jung HJ, Ahn HJ, Kim BI: Improvements in oral functions of elderly after simple oral exercise . Clinical interventions in aging 2019, 14 :915-924. Shirobe M, Watanabe Y, Tanaka T, Hirano H, Kikutani T, Nakajo K, Sato T, Furuya J, Minakuchi S, Iijima K: Effect of an Oral Frailty Measures Program on Community-Dwelling Elderly People: A Cluster-Randomized Controlled Trial . Gerontology 2022, 68 (4):377-386. Beaudart C, Sanchez-Rodriguez D, Locquet M, Reginster JY, Lengelé L, Bruyère O: Malnutrition as a Strong Predictor of the Onset of Sarcopenia . Nutrients 2019, 11 (12). Ahn-Jarvis JH, Piancino MG: Chapter 14: Impact of Oral Health on Diet/Nutrition . Monographs in oral science 2020, 28 :134-147. Nakao Y, Uchiyama Y, Honda K, Yamashita T, Saito S, Domen K: Age-related composition changes in swallowing-related muscles: a Dixon MRI study . Aging clinical and experimental research 2021, 33 (12):3205-3213. Iwasaki M, Shirobe M, Motokawa K, Tanaka T, Ikebe K, Ueda T, Minakuchi S, Akishita M, Arai H, Iijima K et al : Prevalence of oral frailty and its association with dietary variety, social engagement, and physical frailty: Results from the Oral Frailty 5-Item Checklist . Geriatrics & gerontology international 2024, 24 (4):371-377. O'Connor JP, Milledge KL, O'Leary F, Cumming R, Eberhard J, Hirani V: Poor dietary intake of nutrients and food groups are associated with increased risk of periodontal disease among community-dwelling older adults: a systematic literature review . Nutrition reviews 2020, 78 (2):175-188. Additional Declarations No competing interests reported. Supplementary Files STROBEchecklist.docx Cite Share Download PDF Status: Published Journal Publication published 30 Dec, 2025 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 29 Sep, 2025 Reviews received at journal 25 Sep, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviews received at journal 21 Sep, 2025 Reviewers agreed at journal 19 Sep, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviews received at journal 20 Aug, 2025 Reviewers agreed at journal 20 Aug, 2025 Reviewers invited by journal 09 Aug, 2025 Editor assigned by journal 07 Aug, 2025 Submission checks completed at journal 07 Aug, 2025 First submitted to journal 28 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7233960","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":500795883,"identity":"eea98e4f-ca6a-4eda-a857-ef08b001fc15","order_by":0,"name":"Lijuan Liu","email":"","orcid":"","institution":"Hemodialysis Room, Sichuan University, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Lijuan","middleName":"","lastName":"Liu","suffix":""},{"id":500795884,"identity":"10463ebc-42c1-4847-9f50-648bc7fdcefe","order_by":1,"name":"Sikai Tang","email":"","orcid":"","institution":"Hemodialysis Room, Sichuan University, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Sikai","middleName":"","lastName":"Tang","suffix":""},{"id":500795885,"identity":"5483490f-2bc4-4957-ad4d-901fa793b263","order_by":2,"name":"Lin Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYDACdh4Yi/nAgQ8/iNHCDNEiwcDAlnhwZg9pWniMD3OwEaGDv5n3mDRvm00dv0TOh8MMPAzy/GIH8GuROMyXbDizLU1CckbuhsMFFgyGM2cn4NdiwMxj+OBj22EJgxtALTN4GBIMbhPWYnAgse0/UEvOg8M8bMRpAdlyAKSFgTgtEod5jA1nnEuWnNnzzAAYyBKE/cLf3mMmzVNmx8/Pnvz4w4cfNvL80gS0YNhKmvJRMApGwSgYBdgBAIIsPtAlgQQJAAAAAElFTkSuQmCC","orcid":"","institution":"Hemodialysis Room, Sichuan University, Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Lin","middleName":"","lastName":"Chen","suffix":""},{"id":500795886,"identity":"c8d9764a-b7c5-4960-acaf-a53c16bfd9c8","order_by":3,"name":"Li Yang","email":"","orcid":"","institution":"Hemodialysis Room, Sichuan University, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Yang","suffix":""},{"id":500795887,"identity":"9a624c33-b1b8-460d-84ed-edb8b7f13fdd","order_by":4,"name":"Qiuyan Zhao","email":"","orcid":"","institution":"General Practice Ward/International Medical Center Ward, General Practice Medical Center, Sichuan University, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Qiuyan","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2025-07-28 12:38:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7233960/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7233960/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-025-07303-5","type":"published","date":"2025-12-30T15:58:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":99545424,"identity":"b17af434-4600-4b59-afe9-2520ef4115d8","added_by":"auto","created_at":"2026-01-05 16:07:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3120494,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7233960/v1/71e48dc9-e5f1-4bbb-b096-ad6d6dbdd295.pdf"},{"id":89271417,"identity":"158c1370-b59f-4df7-805d-b735e136d3a7","added_by":"auto","created_at":"2025-08-18 08:55:54","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20156,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7233960/v1/a51f37b8a9b604eaaef395a7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Chewing ability and its associated factors in maintenance hemodialysis patients: A cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHemodialysis (HD) is one of the most important renal replacement therapies for end-stage renal disease. By the end of 2023, the number of patients undergoing HD in China had reached approximately 916,000, exhibiting a sustained annual increase. With the development of medical technology, the life expectancy of maintenance hemodialysis (MHD) patients has been extended, which increases the financial burden, the cost of support, and the demand for long-term care. Oral health plays a pivotal role in systemic well-being [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], recognized by the World Health Assembly in 2021 as a global health priority [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, the 4th National Oral Health Epidemiology Survey revealed poor oral health conditions among Chinese adults [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and dental expenditure was at a lower level than in developed countries [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Oral disease in adults with HD is very common [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], but few studies give attention.\u003c/p\u003e\u003cp\u003eChewing is a process that includes predation, crushing and mixing of food, the formation of a bolus, and delivery to the pharynx, which greatly impact food intake [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It can be observed for a comprehensive evaluation of oral function [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Mastication stimulates gut motility and fluid secretion through the cephalic–vagal reflex, aiding digestion and nutrient absorption [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Instead, chewing difficulty causes indigestion and malabsorption [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As the process of indigestion and malnutrition intensifies, it further leads to sarcopenia, frailty, and impaired ADL (activity of daily living) [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, decreased chewing ability lowers the related quality of life and affects mental health issues such as increasing the incidence of depression [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eChewing ability is usually assessed by three methods: direct objective, indirect, and subjective assessment [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. There is considerable variation in different assessments. Subjective reports are often influenced by subjects' food avoidance behaviors, personal preferences, nutritional habits, etc., and there is a tendency for overestimation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In contrast, objective assessments are valid and reliable. Previous studies have shown that the decline in masticatory function is related to gender, age, number of teeth, level of education, etc [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e–\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, the main study population of these studies was mostly community-dwelling elderly people, and the epidemiological characteristics of decreased masticatory function in the general population may not apply to MHD patients, which deserves to be investigated. Therefore, this study aims to investigate the current status of chewing ability in MHD patients, analyze their influencing factors, and provide reference for the implementation of scientific oral health management by healthcare workers in dialysis units.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was a cross-sectional study design and is reported according to the STROBE principle. A cluster sampling method was performed to include MHD patients in a tertiary hospital in Chengdu, from July to October 2024. Inclusion criteria were as follows：(1) aged 55 years or older; (2) regular dialysis 2-3 times per week; (3) voluntary participation in this study. Patients with the following conditions would be excluded:(1) oral surgery or tooth extraction in the last 1 month; (2) hospitalized; (3) dementia or mental illness. This study was approved by the Institutional Review Board of Sichuan University. All participants were investigated after providing the relevant informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA color-changeable gum (Masticatory Performance Evaluating Gum XYLITOL, Lotte Co, Ltd., Tokyo, Japan) was used to assess chewing ability. It was distributed to the patients by the researcher, and they were instructed to chew left and right for 30 each, for a total of 1 minute. In order to obtain the actual value, the patients were asked to remove the removable dentures if any were worn. When it was taken out, the researcher assessed the chewing ability according to the color chart comparing the color of chewed gums with a total of 5 color grades, with grade 1 being green and grade 5 being red. Grades 1-2 were classified as \u0026ldquo;decreased chewing difficulty\u0026rdquo;, and grades 3-5 were classified as \u0026ldquo;normal chewing ability\u0026rdquo;[23, 24].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGeneral information includes age, gender, education, marital status, personal monthly income, and duration of dialysis. Oral health-related information was collected, including the number of remaining teeth, using dental floss, frequency of brushing, and dental cleaning [25]. Subjective chewing difficulty and low articulatory oral motor skills were indicated by a response of \u0026ldquo;yes\u0026rdquo; to the self-reported questions: \u0026ldquo;Do you have any difficulties eating tough foods now compared with 6\u0026thinsp;months ago?\u0026rdquo; and \u0026ldquo;Have you had difficulty in clear pronunciation recently?\u0026rdquo; [26, 27]. Depression and anxiety symptoms were assessed using the 5-item Geriatric Depression Scale (GDS-5: range 0 to 5) [28] and the 7-item Generalized Anxiety Disorder (GAD-7) (GAD-7: range 0 to 21) [29], respectively. Depressive symptoms were defined as a GDS score \u0026ge;2, and anxiety symptoms were defined as a GAD score \u0026ge;5. Barthel index (BI) measured the independence and functional ability in ADL (BI score: range 0 to 100) [30]. The original 10-item form of the BI consisted of 10 common ADL activities. Impaired ADL was defined as a BI score \u0026lt;100. Malnutrition was assessed by the Malnutrition-inflammation Score (MIS) [31]. The MIS consists of 4 parts (medical history, physical examination, body mass index, and laboratory values) and 10 components in total (MIS score: range 0 to 10). A higher score reflects a more severe degree of malnutrition and inflammation. An MIS \u0026ge;8 was defined as malnutrition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was conducted via the Questionnaire Star platform(www.wjx.cn) using face-to-face interviews. All investigators were HD nursing staff who used a unified guide for data collection. When the patients had unclear questions, they were given guidance in time. Before the formal survey, the purpose, methodology, and significance of the study were explained to the subjects to obtain informed consent and sign the relevant informed consent form. The surveys were all during dialysis. The remaining part of the questionnaire was filled in after the chewing gum test was completed. Each questionnaire required 10-15 minutes to complete.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was performed using SPSS 26.0 software (IBM Corporation, Armonk, NY, USA). Quantitative data was depicted with frequencies (n) and percentages (%). The Chi-square test was used to analyze the difference groups between normal and decreased chewing ability. Before multivariable analysis, collinearity diagnostics were performed on independent variables. Variables were retained only if they met the following criteria: variance inflation factor (VIF) \u0026lt; 10 and tolerance \u0026gt; 0.1. To control confounding bias and determine variables independently associated with chewing ability in the sample, a multivariate logistic regression model (Forward: LR) was performed with selected variables showing a p-value of \u0026lt;0.05 in the univariate analysis. Odds ratios (ORs) and their respective 95% confidential intervals (CIs) were calculated. A p-value \u0026lt;0.05 was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 154 MHD patients were included in this study. Among them, 27.3% of the patients were defined as decreased chewing ability, and 43.5% of them aged over 70 years old. The majority of the patients were male (58.4%). A significant proportion had a college degree or above (44.2%), subjective chewing difficulty (55.8%), and had undergone treatment over 5 years (66.2%). See detail in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eUnivariate analysis with the presence of decreased chewing ability as the dependent variable showed that there were statistical differences between the two groups in terms of age, subjective chewing difficulty, low articulatory oral motor skills, number of remaining teeth, dental floss, depression, malnutrition, and ADL (p\u0026thinsp;\u0026lt;\u0026thinsp;.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eFor the collinearity diagnostics, the results showed that the tolerance values were \u0026gt;\u0026thinsp;0.591 and the VIF were \u0026lt;\u0026thinsp;1.693, indicating that there was no significant covariance between the included independent variables for further analysis. Taking whether the MHD patients had decreased chewing ability as the dependent variable, the value of normal chewing ability was 1 and decreased was 2. The results of binary logistic analysis showed that the number of remaining teeth\u0026thinsp;\u0026lt;\u0026thinsp;20 (OR\u0026thinsp;=\u0026thinsp;4.657, 95%CI: 1.910-11.353), subjective chewing difficulty (OR\u0026thinsp;=\u0026thinsp;3.399, 95%CI: 1.224\u0026ndash;9.438), low articulatory oral motor skills (OR\u0026thinsp;=\u0026thinsp;3.654, 95%CI: 1.466\u0026ndash;9.104), malnutrition (OR\u0026thinsp;=\u0026thinsp;4.913, 95%CI: 1.819\u0026ndash;13.271) were the influencing factors of chewing ability in MHD patients, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGeneral information (n\u0026thinsp;=\u0026thinsp;154)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, \u003cem\u003eyears\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87(56.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67(43.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e90(58.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64(41.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary school and below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24(15.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29(18.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33(21.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCollege degree or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68(44.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e126(81.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28(18.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersonal income monthly, \u003cem\u003eyuan\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;4000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58(37.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;4000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96(62.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of dialysis, \u003cem\u003eyears\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52(33.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e102(66.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubject chewing difficulty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68(44.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e86(55.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow articulatory oral motor skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e107(69.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47(30.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of remaining teeth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54(35.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100(64.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTooth brushing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;2 times per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58(37.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2 times per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96(62.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDental floss\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79(51.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75(48.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24(15.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e130(84.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47(30.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e107(69.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalnutrition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32(20.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e122(79.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImpaired ADL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96(62.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58(37.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison and univariate analysis of the chewing ability in MHD patients (n\u0026thinsp;=\u0026thinsp;154)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;42\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDecreased chewing ability\u003c/p\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;112\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eχ2\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, \u003cem\u003eyears\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21.576\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11(26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e76(67.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31(73.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36(32.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.694\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.193\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69(61.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43(38.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.192\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary school and below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11(26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13(11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6(14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23(20.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6(14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27(24.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege degree or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19(45.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49(43.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.268\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32(76.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e94(83.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10(23.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18(16.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersonal income monthly, \u003cem\u003eyuan\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.293\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;4000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13(31.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45(40.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;4000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29(69.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67(59.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of dialysis, \u003cem\u003eyears\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.945\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14(33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38(33.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28(66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74(66.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubject chewing difficulty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.697\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7(16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61(54.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35(83.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51(45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow articulatory oral motor skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22.911\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17(40.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e90(80.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25(59.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22(19.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of remaining teeth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28(66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26(23.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14(33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e86(76.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTooth brushing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.664\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.415\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;2 times per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18(42.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40(35.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2 times per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24(57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72(64.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDental floss\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.367\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30(71.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49(43.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12(28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63(56.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.526\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.468\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34(81.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96(85.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8(19.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16(14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.900\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23(54.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e84(75.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19(45.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28(25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalnutrition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.987\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23(54.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e99(88.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19(45.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13(11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImpaired ADL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.456\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16(38.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80(71.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26(61.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32(28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLogistic regression analysis of the chewing ability of the MHD patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eWald\u003c/em\u003e χ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eOR (95%CI)\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of remaining teeth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.00 (Reference)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.538\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.455\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.447\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.657 (1.910\u0026minus;11.353)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubjective chewing difficulty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.00 (Reference)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.521\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.516\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.399 (1.224\u0026ndash;9.438)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow articulatory oral motor skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.00 (Reference)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.296\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.466\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.736\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.654 (1.466\u0026ndash;9.104)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalnutrition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.00 (Reference)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.592\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.507\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.858\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.913 (1.819\u0026ndash;13.271)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;3.368\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.533\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39.901\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that the prevalence of decreased chewing ability in MHD patients was 27.3%, which was higher than that of the general population (14.1%-20.0%) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Possibly due to the different study populations, MHD patients commonly have impaired salivary gland function, which is directly related to systemic dehydration status and insufficient glandular perfusion, and is often manifested as dry mouth[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Inadequate secretion of saliva, an important lubricant and digestive fluid in the oral cavity, directly affects food moistening, dough formation, and initial digestion, leading to significant discomfort and reduced efficiency during chewing. In addition, inadequate dialysis also leads to disruptions in calcium and phosphorus metabolism, lowering blood calcium levels, which increases the risk of tooth loss in MHD patients [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Recently, oral frailty is commonly used to describe oral health and function. Several studies have shown a high prevalence of oral frailty in MHD patients (45.2%-69.2%) [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Then, there is a lack of specific assessment tools for oral frailty in MHD patients, and their tools are subjective screening tools, including the assessment of subjective dry mouth, which may lead to a high detection rate and affect the accuracy of the assessment. Then, it has been suggested that chewing difficulties should be included in geriatric syndromes as a comprehensive assessment of oral function [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Color-changeable gum has been confirmed its validity and is widely used in the assessment of chewing ability in older people [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, the objective chewing ability assessment method used in our current study is considered to give more reasonable epidemiologic data on the oral status of MHD patients.\u003c/p\u003e\u003cp\u003eThis study shows that the number of remaining teeth is a key factor affecting chewing ability, which is consistent with previous studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The World Health Organization set 20 teeth as the maintenance of normal chewing ability [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Reduced number of teeth directly affects the chewing ability of MHD patients, especially the loss of posterior teeth [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Periodontal tissue lesions in HD patients are characterized by early onset and high progression, which are significantly higher than those in the general population. The mean number of natural teeth of HD in this study was 19.76, which was lower than the average (24) of the 4th National Oral Health Epidemiology Survey in China [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Patients undergoing MHD exhibit not only increased incidences of gingival bleeding and swelling, but also progressive manifestations of severe periodontopathies, including gingival recession, root exposure, periodontal suppuration, and accelerated alveolar bone resorption [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Destruction of periodontal supportive tissues directly leads to decreased tooth stability, making it impossible for patients to grind food effectively during chewing due to loose teeth, especially fibrous foods or foods that require greater bite force. In addition, the required routine visits for dialysis sessions can make it difficult for HD patients to reserve time to visit dentists for check-ups or treatment, which makes it difficult for MHD patients to maintain good oral health [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. It suggests that healthcare providers in HD units should pay attention to the oral status of MHD patients and incorporate it into the whole management system, and should carry out restorative treatment in time for patients with the number of remaining teeth\u0026thinsp;\u0026lt;\u0026thinsp;20.\u003c/p\u003e\u003cp\u003eIn this study, we found that MHD patients with subjective chewing difficulties were more likely to have decreased chewing ability. Self-assessed health status is a reflection of an individual's overall perception of their current health status. Individuals' subjective perceptions may appear earlier than disease manifestations and can provide important health information for potential risk groups [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Self-reports of chewing difficulties still have good predictive value, although a tendency towards overestimation has been noted. Martin et al. [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] view self-assessed health status as an important tool for understanding an individual's health status and reflecting changes in the individual's health trajectory. Clinical practice should prioritize enhancing self-awareness of oral health status among MHD patients. Implementing dynamic self-assessment protocols enables the timely detection of oral health deterioration. HD healthcare providers and family caregivers can utilize these self-reported outcomes to initiate evidence-based screenings and targeted interventions, thereby preventing or mitigating the decline of chewing ability.\u003c/p\u003e\u003cp\u003eIn the present study, low articulatory oral motor skills were found to be an influential factor in chewing ability, which is similar to the results of the previous study [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Mastication constitutes a complex sensorimotor process reliant on coordinated neuromuscular activity among orofacial structures. In MHD patients, accumulated guanidine compounds inflict neurotoxic damage to the trigeminal motor nuclei and facial nerve branches governing lip and tongue movement, thereby impairing the synchronized contraction of masticatory and articulatory muscle groups [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. In addition, MHD patients are often affected by the disease with social withdrawal, reduced verbal communication, and a corresponding decrease in muscle strength, resulting in poor chewing ability. Some rehabilitation exercises are necessary. Evidence suggests that some oral exercises can be performed to improve chewing ability in community-dwelling older adults [\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], but further studies are needed in dialysis populations.\u003c/p\u003e\u003cp\u003eMalnutrition is significantly associated with decreased chewing ability in MHD patients. Protein-energy wasting (PEW) is more common in MHD patients due to nutrient loss on dialysis, increasing the risk of sarcopenia and frailty [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Prolonged protein loss leads to decreased muscle mass and muscle strength, including a range of oral muscle groups such as the tongue and masticatory muscles, which negatively affects chewing ability [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. In turn, MHD patients with decreased chewing ability often have inadequate food intake and reduced food variety, further exacerbating malnutrition and establishing a bidirectional deterioration cycle [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. MHD patients should undergo quarterly nutritional risk screening, implement dietary optimization with texture-modified foods and targeted nutrient supplementation, maintain rigorous oral hygiene, and initiate preventive masticatory exercises to mitigate functional decline and improve systemic health outcomes.\u003c/p\u003e\u003cp\u003eThis study had several limitations. First, this study was a single-center design with a limited sample size. This may impact the generalizability of the study. Second, causality cannot be firmly established due to the cross-sectional study design. Finally, some potential influencing factors were not included, such as uremic toxin quantification and vitamin D deficiency. Future studies should also incorporate multicenter longitudinal studies to establish causal relationships between the prevalence of chewing ability and various factors in MHD patients.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e This study revealed a prevalence of decreased chewing ability was 27.3% in MHD patients, and number of remaining teeth, subjective chewing difficulty, low articulatory oral motor skills, and malnutrition were the factors associated with chewing ability. Color-changeable gum can be used for early detection of chewing function in MHD patients. These findings suggested that healthcare providers should be attentive to the oral status of patients with MHD, to self-reported outcomes, and to timely completion of nutritional screenings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003ecknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all staff members and participants of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003cstrong\u003eunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Natural Science Foundation of Sichuan Province [Grant Number: 2024NSFSC1607].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003eonflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLin Chen and Sikai Tang designed the study. Li Yang and Lijuan Liu collected the data. Sikai Tang and Qiuyan Zhao participated in checking the data and performed the statistical analysis. Lijuan Liu and Sikai Tang draft the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe design and implementation of the present study were conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of West China Hospital of Sichuan University. All participants were investigated after providing the relevant informed consent.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBaiju RM, Peter E, Varghese NO, Sivaram R: \u003cstrong\u003eOral Health and Quality of Life: Current Concepts\u003c/strong\u003e. \u003cem\u003eJournal of clinical and diagnostic research : JCDR\u0026nbsp;\u003c/em\u003e2017, \u003cstrong\u003e11\u003c/strong\u003e(6):Ze21-ze26.\u003c/li\u003e\n \u003cli\u003eZupo R, Castellana F, De Nucci S, Dibello V, Lozupone M, Giannelli G, De Pergola G, Panza F, Sardone R, Boeing H: \u003cstrong\u003eBeverages Consumption and Oral Health in the Aging Population: A Systematic Review\u003c/strong\u003e. \u003cem\u003eFrontiers in nutrition\u0026nbsp;\u003c/em\u003e2021, \u003cstrong\u003e8\u003c/strong\u003e:762383.\u003c/li\u003e\n \u003cli\u003eCheng ML, Wang CX, Wang X, Feng XP, Tai BJ, De Hu Y, Lin HC, Wang B, Zheng SG, Liu XN\u003cem\u003e\u0026nbsp;et al\u003c/em\u003e: \u003cstrong\u003eDental expenditure, progressivity and horizontal inequality in Chinese adults: based on the 4th National Oral Health Epidemiology Survey\u003c/strong\u003e. \u003cem\u003eBMC oral health\u0026nbsp;\u003c/em\u003e2020, \u003cstrong\u003e20\u003c/strong\u003e(1):137.\u003c/li\u003e\n \u003cli\u003eZaitsu T, Saito T, Kawaguchi Y: \u003cstrong\u003eThe Oral Healthcare System in Japan\u003c/strong\u003e. \u003cem\u003eHealthcare (Basel, Switzerland)\u0026nbsp;\u003c/em\u003e2018, \u003cstrong\u003e6\u003c/strong\u003e(3).\u003c/li\u003e\n \u003cli\u003eBindi M, Paganelli C, Eaton KA, Widstr\u0026ouml;m E: \u003cstrong\u003eThe healthcare system and the provision of oral healthcare in European Union member states. 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gerontology international\u0026nbsp;\u003c/em\u003e2024, \u003cstrong\u003e24\u003c/strong\u003e(4):371-377.\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Connor JP, Milledge KL, O\u0026apos;Leary F, Cumming R, Eberhard J, Hirani V: \u003cstrong\u003ePoor dietary intake of nutrients and food groups are associated with increased risk of periodontal disease among community-dwelling older adults: a systematic literature review\u003c/strong\u003e. \u003cem\u003eNutrition reviews\u0026nbsp;\u003c/em\u003e2020, \u003cstrong\u003e78\u003c/strong\u003e(2):175-188.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"oral function, chewing ability, hemodialysis, cross-sectional study","lastPublishedDoi":"10.21203/rs.3.rs-7233960/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7233960/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eChewing difficulty is prevalent yet understudied in maintenance hemodialysis (MHD) patients, despite its critical role in overall health. This study aimed to investigate the current status of chewing ability and its associated factors in Chinese MHD patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted at a tertiary hospital in Chengdu from July to October 2024. Chewing ability was objectively assessed using color-changeable gum, with grades 1\u0026ndash;2 defining decreased function. Other variables included general information, anxiety and depression symptoms, nutritional status, and activity of daily life (ADL). Multivariable logistic regression identified the factors influencing chewing ability.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 154 MHD patients aged\u0026thinsp;\u0026ge;\u0026thinsp;55 years were included in this study, and the prevalence of decreased chewing ability was 27.3%. Associated factors included: number of remaining teeth\u0026thinsp;\u0026lt;\u0026thinsp;20 (OR\u0026thinsp;=\u0026thinsp;4.657, 95%CI: 1.910-11.353), subjective chewing difficulty (OR\u0026thinsp;=\u0026thinsp;3.399, 95%CI: 1.224\u0026ndash;9.438), low articulatory oral motor skills (OR\u0026thinsp;=\u0026thinsp;3.654, 95%CI: 1.466\u0026ndash;9.104), and malnutrition (OR\u0026thinsp;=\u0026thinsp;4.913, 95%CI: 1.819\u0026ndash;13.271) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eMHD patients are more likely to have decreased chewing ability than the general population. HD staff can provide comprehensive management based on oral status examinations, self-reports of oral health outcomes, and validated nutritional screenings.\u003c/p\u003e","manuscriptTitle":"Chewing ability and its associated factors in maintenance hemodialysis patients: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-18 08:55:49","doi":"10.21203/rs.3.rs-7233960/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-29T06:27:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-26T01:54:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284312662802628866610306896427850079436","date":"2025-09-22T14:20:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-21T05:25:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33676129242092179392665712702831210201","date":"2025-09-19T12:54:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309373011230127346904875065794855484611","date":"2025-08-25T08:50:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-20T09:57:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289661761902598700331625489342417251240","date":"2025-08-20T07:11:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-09T19:28:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-07T07:10:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-07T07:09:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-07-28T12:31:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6868eb4e-e78d-453c-b63a-bfce58fe4f48","owner":[],"postedDate":"August 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:03:58+00:00","versionOfRecord":{"articleIdentity":"rs-7233960","link":"https://doi.org/10.1186/s12903-025-07303-5","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2025-12-30 15:58:13","publishedOnDateReadable":"December 30th, 2025"},"versionCreatedAt":"2025-08-18 08:55:49","video":"","vorDoi":"10.1186/s12903-025-07303-5","vorDoiUrl":"https://doi.org/10.1186/s12903-025-07303-5","workflowStages":[]},"version":"v1","identity":"rs-7233960","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7233960","identity":"rs-7233960","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}