Exploring bite force as an indicator of frailty phenotype: a pilot study

Exploring bite force as an indicator of frailty phenotype: a pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring bite force as an indicator of frailty phenotype: a pilot study Luciano Maia Alves Ferreira, Robson Dias Scoz, Josie Resende Torres Silva, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4607026/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives The aim of the study was to explore the correlation between bite force and grip strength as measures of frailty in the elderly. Materials and Methods Elderly people completed a socio-demographic questionnaire, protocols for measuring bite force, handgrip strength using dynamometry and body composition analysis using electrical bioimpedance. Statistical analyses were carried out to assess the association between these variables. Results We assessed 59 participants. The results indicate a positive correlation between bite force and grip strength, even after controlling for age and body mass index (BMI). There are positive and significant correlations between BITE and GRIP forces, which means that increases (decreases) in bite force values are accompanied by increases (decreases) in handgrip force values. Conclusion Our results suggest that decreased bite strength may increase the risk of frailty over time. In conclusion, the study suggests that bite force can serve as a useful indicator of frailty risk in the elderly and calls for further research to validate these initial results in larger samples. This correlation emphasises the importance of oral health in the care of the elderly and in frailty prevention strategies. Bite force Hand grip Frailty Oral health Phenotype Figures Figure 1 Introduction Ageing population has gained prominence because of its rapid and extensive occurrence. This situation presents significant challenges in obtaining resources to implement public policies promoting active ageing and addressing common multiple comorbidities within populations ( 1 ). These health issues contribute to the development of geriatric syndromes, which in turn can hinder the autonomy and independence of the elderly, known as frailty ( 2 ). This can result in disability, vulnerability, institutionalisation, and ultimately, an earlier than expected death ( 3 – 5 ). Recognizing groups of vulnerabilities and limitations can help identify frailty, a clinical syndrome characterised by the presence of three or more of the following criteria: involuntary weight loss (of 4.5 kilograms or more in the previous year), self-reported exhaustion, weakness indicated by grip strength, slow walking speed and levels low levels of physical activity ( 6 ). Frailty is closely associated with greater vulnerability to negative health consequences and greater susceptibility to adverse physical outcomes, especially in elderly populations. While the frailty-aging axis is not necessarily a direct result of the natural process per se , it remains a significant factor to consider ( 5 ). Several criteria have been presented to identify frailty, and can also be assessed by the accumulation of physiological and/or functional deficits ( 4 , 7 ). These characteristics are causes and consequences of the accumulation of subclinical conditions, acute or chronic. The connection between frailty and several phenotypes, such as muscle weakness, bone fragility, low body mass index, increased risk of falls, susceptibility to trauma, heightened risk of infections, fluctuating blood pressure, and varying extents of physical capability impairment, is widely acknowledged. ( 8 – 10 ). As a syndrome targeting all systems in the body, frailty and oral health have been studied by Miura et al. ( 11 ), using physical measures (bite strength), with an emphasis on specific data obtained using the Dental Prescale system ( 11 ). In their results, bite force was found to vary in healthy elderly people, with men having greater strength. In addition, frail elderly people were reported to show a significantly lower bite force compared to their healthy counterparts, and correlated with the number of teeth present. Expectedly, the same group suggested considering guidelines to improve chewing and oral health care should increase in the future ( 12 ). The intriguing outcomes of this study lay the groundwork for the potential usefulness of biteforce in detecting frailty. Yet, its correlation with hand grip, a standard measure of comparable frailty indicators, has not been investigated before. Exploring this correlation could bolster the potential of biteforce as a diagnostic tool for frailty. Using a sample of elderly people, we aimed to explore whether bite force correlates with measures of grip strength. Materials and Methods 2.1. Design and Setting This cross-sectional study follows the recommendations of the case-control studies checklist of the Strengthening the Reporting of Observational studies in Epidemiology guideline ( 13 ). This study was conducted at Egas Moniz School of Health and Science between January and May 2023. Elderly people attending campus clinics in Monte da Caparica (Almada, Portugal) were invited to participate in this study. This study was approved by the Ethics Committee of Egas Moniz (ID 1104/2022) and carried out according to the Helsinki declaration (as per its 2013 revision). Participants initially signed an informed consent form containing all information related to the study, including privacy and confidentiality terms, risks and benefits of the study, and possibility of withdrawing at any time. 2.2. Eligibility Criteria To be eligible, participants must had 60 years old or more, have functional teeth (at least 20 teeth) and present a state of cognition and oral functionality for independent individuals. Exclusion criteria include having more than 20 teeth lost by any reason, being completely toothless, having any clinical diagnosis of dementia-related neurological pathology. 2.3. Bite force measurement and protocol Bite force was recorded using an electric dynamometer (EMG System ®, São José dos Campos, São Paulo, Brazil). Participants were instructed through a demonstration were allowed to test the device one time before recording. Once fitted intra-orally, each participant remained seated and rested. They had a computer screen as biofeedback to monitor the result of the bite strength grading. Data collection was carried out in 3 full strength bite attempts lasting 10 seconds, with a 1-minute rest interval between each attempt ( 14 ). The subjects seated in a chair without armrest, will feel fully resting on the floor, hips as far back in the chair as possible, and the hips and knee positioned at approximately 90°. Additional standardized instructions were given, using a pre-defined message in a card as follows: "This test will tell me your maximum bite strength. When I say go, bite as hard as you can until I say stop. Before each attempt, I will ask, 'Are you Ready?” and then I will say ‘Go.’ Stop immediately if you feel any unusual pain or discomfort at any time during the test. 2.4. Handgrip measurements and protocol To record the handgrip strength, we used the K-Grip-Link® (Kinvent Physio, Montpellier, France) and values collected were presented in Kg/F. The mechanical parts were properly sanitised and calibrated according to manufacturer's instructions. The elderly received information about the test and had a tablet screen as biofeedback to monitor the result of the strength measurement. Data collection was carried out in 3 series lasting 10 seconds, with a 1-minute rest interval, standardised by the K-Physio APP. The subjects seated in a chair without armrest, will feel fully resting on the floor, hips as far back in the chair as possible, and the hips and knee positioned at approximately 90°. Shoulder Adducted and neutrally rotated, elbow flexed to 90°, they should be in mid prone (neutral) and the Wrist Between 15–30° of extension (dorsiflexion) and 0–15° of ulnar deviation. The following instructions were made. "This test will tell me your maximum grip strength. When I say go, squeeze as hard as you can until I say stop. Before each attempt, I will ask, 'Are you Ready?” and then I will say ‘Go.’ Stop immediately if you feel any unusual pain or discomfort at any time during the test¹⁷. 2.5. Bioelectrical impedance analysis Body composition measurement was carried out using bioelectrical impedance analysis with the model ACCUNIQ BC310 (Korea). The software analyzed identity, height, age, sex, and body weight to produce an automatic report with the results of the Body Mass Index (BMI). Participants were assessed in the morning, after an overnight fast, and were instructed to abstain from physical exercise and stimulating beverages such as coffee or energy drinks for the last 24 hours before the measurement. Participants were instructed to remove all metallic objects, including earrings, rings, and belts, and to wear as little clothing as possible. They were then positioned barefoot and without socks on top of the scale, with their feet parallel, on top of the plantar sensors. The arms were positioned close to the body, holding the palm sensors, and it was necessary to press the start button with both thumbs simultaneously for approximately 10 seconds (factory default) to begin the measurement. Following the measurement, the elderly participants were assisted in getting off the scale and instructed to dress and wear shoes throughout the assessment ( 15 ). 2.6. Statistical Analysis The degree of association between BITE and GRIP forces after removal of the effect of confounding variables was evaluated using partial correlation coefficients. To identify potential confounding variables of this association, Pearson's correlation coefficient was used after verification of the univariate normality of the variables involved, using the Shapiro-Wilk normality test. These statistical procedures were implemented with IBM 29.0 software (Armonk, New York), at a significance level of 5%. Results 3.1. Participants characteristics Fifty-nine participants completed this exploratory clinical study, without exclusions. Overall, the mean age was 77.6 years (± 9.5) and were mostly women (70.0%, n = 43) and 37.3% were institutionalised (Table 1 ). Table 1 Characteristics of participants Variable Males (n = 16) Females (n = 43) p-value Total Height (cm) 164.1 (5.2) 153.7 (6.6) 156.5 (7.8) Weight (Kg) 75.1 ( 11 ) 66.4 (14.2) 68.8 (13.6) BMI 27.8 ( 4 ) 28.3 (5.7) 28.2 (5.2) Bite 17.2 (7.7) 14.8 (5.7) 15.5 (6.3) RMGrip 20 ( 8 ) 11.8 (4.9) 14 (6.7) LMGrip 18.7 (7.5) 11.7 (4.7) 13.6 (6.3) RAGrip 16.9 (6.6) 10 (4.6) 11.9 (5.9) LAGrip 16 (6.7) 10 (4.3) 11.7 (5.6) BMI - Body Mass Index, Bite - Bite Maximum Strength, RMGrip - Right Handgrip Maximum Strength, LMGrip - Left Handgrip Maximum Strength, RAGrip - Right Handgrip Average Strength, LAGrip - Left Handgrip Average Strength. 3.2. Biteforce and hand grip Before assessing the association between bite and grip forces, we explored age and BMI as potential confounding variables. We applied the Pearson's correlation coefficient after checking the univariate normality of the variables involved (Table 2 ). Age was significantly correlated with bite and grip forces (p < 0.05), while BMI only correlated with handgrip forces but not bite force (coefficient= -0.047, p = 0.737). Table 2 Correlations unadjusted between Age, BMI, bite force and handgrip strength. Age BMI BITE RMGrip LMGrip RAGrip BMI Correlation -0.329 * 1.000 - p 0.011 - - df 59 0 - BITE Correlation -0.321 * -0.047 1.000 - p 0.018 0.737 - - df 54 54 0 - RMGrip Correlation -0.340 ** 0.316 * 0.448 ** 1.000 - p 0.008 0.015 < 0.001 - - df 59 59 54 0 - LMGrip Correlation -0.414 ** 0.295 * 0.497 ** 0.911 ** 1.000 - p 0.001 0.023 < 0.001 < 0.001 - - df 59 59 54 59 0 - RAGrip Correlation -0.387 ** 0.347 ** 0.447 ** 0.979 ** 0.904 ** 1.000 p 0.002 0.007 < 0.001 < 0.001 < 0.001 - df 59 59 54 59 59 0 LAGrip Correlation -0.424 ** 0.290 * 0.496 ** 0.894 ** 0.993 ** 0.895 ** p < 0.001 0.026 < 0.001 < 0.001 < 0.001 < 0.001 df 59 59 54 59 59 59 *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). Under these conditions, the partial correlations between the BITE and GRIP forces were calculated, controlling simultaneously for age and body mass index, with the results shown in Table 2 . Table 3 Correlations adjusted for Age and BMI Control Variables BITE RMGrip LMGrip RAGrip LAGrip Age & BMI BITE Correlation 1.000 - - - - p - - - - - df 0 - - - - RMGrip Correlation 0.441 1.000 - - - p 0.001 - - - - df 50 0 - - - LMGrip Correlation 0.469 0.900 1.000 - - p < 0.001 < 0.001 - - - df 50 50 0 - - RAGrip Correlation 0.437 0.977 0.890 1.000 - p 0.001 < 0.001 < 0.001 - - df 50 50 50 0 - LAGrip Correlation 0.464 0.881 0.992 0.878 1.000 p 0.001 < 0.001 < 0.001 < 0.001 - df 50 50 50 50 0 Table 2 shows that, after controlling for potential confounding effects due to age and body composition, bite force (BITE) and handgrip force (GRIP) show significant positive correlations. It should be noted that the partial correlation coefficients in Table 2 differ very little from the zero-order correlation coefficients presented in Table 1 , which suggests that the effects of age and BMI on these correlations are not very relevant. In summary, there are positive and significant correlations between BITE and GRIP forces, which means that increases (decreases) in bite force values are accompanied by increases (decreases) in handgrip force values. Discussion In this exploratory study, the measurement of handgrip strength, a recognised frailty phenotype, was significant correlated with bite force in the elderly, even when adjusted for age and body mass index. The findings of this preliminary study lend to support bite force measurement as a valuable measure for assessing frailty in the elderly. This association is particularly noteworthy given its potential impact on the practical application of this test, which, like the handgrip protocol, is a rapid and straightforward procedure ( 16 ). Unilateral handgrip strength is considered a gold-standard protocol for identifying the risk of frailty and mobility limitations in the elderly, but its defined cut-off points vary according to sex and BMI ( 17 , 18 ). Sallinen et al. carried out a Finnish population-based health survey to determine the optimal cut points in handgrip strength measurement, and explored whether these cut points would be BMI-dependent ( 17 ). Overall, hand-grip strength cut points were reported to increase along with increasing BMI in men but remained equivalent in women at 21 kg. Alas, regardless of sex, when handgrip strength underperformed below the specific BMI cut-off values, participants showed three times higher risk to have mobility limitation. Yet, subsequent research demonstrated this relationship between BMI and handgrip strength in the elderly is still controversial ( 18 ). With this controversy in mind, our results show that biteforce seems to be independent on BMI, but this requires confirmation with larger and prospective cohorts to determine cut offs and to test its performance. Ergo, our data suggests that this type of assessment show potential for clinical use as a criterion (phenotype) for frailty, providing a further argument for discussion on this issue. This goes in line with Iwasaki et al. ( 19 ) where maximum bite force correlated with an increased risk of frailty in the elderly in a prospective cohort of Japanese elders. Following up 322 participants for 5 years, this study explored whether poor oral function, as indicated by low maximum bite force would link to higher risk of developing frailty among elderly men and women. About 15.2 percent of participants developed frailty and the lower tertile of maximum bite force was associated with three times the risk of developing a frailty phenotype ( 19 ). Overall, our preliminary data validate the methodological applicability of biteforce and its correlation with a standard criterion of frailty. We reported this study following the PRISMA guideline which increases the transparency and future replicability. Yet, this study presents shortcomings worth discussing, such as the limited sample of this pilot study. The observational nature of this study precludes any causal relationship and defining robust cut off values. Conclusion Bite force showed a moderate correlation with hand grip strength measurements, showing potential as a frailty diagnostic criterion. Future studies shall explore the validity of these preliminary findings in larger samples to understand whether bite force might be useful in the prediction of elderly frailty risk and to define cut off values. Declarations Conflict of Interests Statement None declared. Funding This research received no external funding. CRediT author statement Luciano Maia: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing - original draft; Writing - review & editing. Robson Dias Scoz : Methodology; Resources; Software; Writing - original draft; Writing - review & editing. Josie Resende Torres da Silva : Writing - review & editing. Marcelo Lourenço da Silva : Writing - review & editing. José Brito : Formal analysis; Writing - review & editing. César Ferreira Amorim : Writing - review & editing. André Júdice : Writing - review & editing. José João Mendes : Supervision, Writing- Reviewing and Editing. Vanessa Machado : curation; Formal analysis; Investigation; Methodology; Writing- Reviewing and Editing. João Botelho: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Writing - original draft; Writing - review & editing. Acknowledgement We acknowledge the support by Sausport in providing material for this project and to FCT/MCTES for the financial support to CiiEM (UIDB/04585/2020) through national funds. References Leng S, Chen X, Mao G. Frailty syndrome: an overview. CIA março de 2014;433. Roman-Liu D. Age-related changes in the range and velocity of postural sway. Archives Gerontol Geriatr julho de. 2018;77:68–80. Ciosak SI, Braz E, Costa MFBNA, Nakano NGR, Rodrigues J, Alencar RA, et al. Senescência e senilidade: novo paradigma na atenção básica de saúde. Rev esc enferm USP dezembro de. 2011;45(spe2):1763–8. Walston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc. junho de. 2006;54(6):991–1001. Fried LP, Cohen AA, Xue QL, Walston J, Bandeen-Roche K, Varadhan R. The physical frailty syndrome as a transition from homeostatic symphony to cacophony. Nat Aging 14 de janeiro de. 2021;1(1):36–46. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 1 de março de. 2001;56(3):M146–57. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 30 de agosto de. 2005;173(5):489–95. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc maio de. 2007;55(5):780–91. Santos RCD, Menezes RMPD, Araújo GKND, Marcolino EDC, Xavier AG, Gonçalves RG et al. Síndrome da fragilidade e fatores associados em idosos no pronto atendimento. Acta Paulista de Enfermagem. 1 de junho de 2020;33:eAPE20190159. Ferrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB, Walston JD, et al. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc abril de. 2004;52(4):625–34. Miura H, Watanabe S, Isogai E, Miura K. Comparison of maximum bite force and dentate status between healthy and frail elderly persons. J Oral Rehabilitation junho de. 2001;28(6):592–5. Manzon L, Vozza I, Poli O. Bite Force in Elderly with Full Natural Dentition and Different Rehabilitation Prosthesis. Int J Environ Res Public Health. 3 de fevereiro de 2021;18(4):1424. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol abril de. 2008;61(4):344–9. Kelencz CA, Muñoz ISS, Amorim CF, Nicolau RA. Effect of Low-Power Gallium–Aluminum–Arsenium Noncoherent Light (640 nm) on Muscle Activity: A Clinical Study. Photomedicine and Laser Surgery. outubro de. 2010;28(5):647–52. Yang SW, Kim TH, Choi HM. The reproducibility and validity verification for body composition measuring devices using bioelectrical impedance analysis in Korean adults. J Exerc Rehabil agosto de. 2018;14(4):621–7. Sousa-Santos AR, Amaral TF. Differences in handgrip strength protocols to identify sarcopenia and frailty - a systematic review. BMC Geriatr dezembro de. 2017;17(1):238. Sallinen J, Stenholm S, Rantanen T, Heliövaara M, Sainio P, Koskinen S. Hand-grip strength cut points to screen older persons at risk for mobility limitation. J Am Geriatr Soc setembro de. 2010;58(9):1721–6. Soraya N, Parwanto E. The Controversial Relationship between Body Mass Index and Handgrip Strength in the Elderly: An Overview. Malays J Med Sci junho de. 2023;30(3):73–83. Iwasaki M, Yoshihara A, Sato N, Sato M, Minagawa K, Shimada M, et al. A 5-year longitudinal study of association of maximum bite force with development of frailty in community‐dwelling older adults. J Oral Rehabilitation janeiro de. 2018;45(1):17–24. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-4607026","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317430623,"identity":"f3427fd5-03ca-4a7f-aec3-e1446135ff0d","order_by":0,"name":"Luciano Maia Alves Ferreira","email":"data:image/png;base64,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","orcid":"","institution":"Egas Moniz School of Health \u0026 Science","correspondingAuthor":true,"prefix":"","firstName":"Luciano","middleName":"Maia Alves","lastName":"Ferreira","suffix":""},{"id":317430624,"identity":"6b05db87-8cb9-4a27-bdb2-912180059334","order_by":1,"name":"Robson Dias Scoz","email":"","orcid":"","institution":"Egas Moniz School of Health \u0026 Science","correspondingAuthor":false,"prefix":"","firstName":"Robson","middleName":"Dias","lastName":"Scoz","suffix":""},{"id":317430625,"identity":"030d3f71-074e-40ed-860b-9022bda3789a","order_by":2,"name":"Josie Resende Torres Silva","email":"","orcid":"","institution":"Neuromodulação e Estudos da Dor (LANNED) - Universidade Federal de Alfenas","correspondingAuthor":false,"prefix":"","firstName":"Josie","middleName":"Resende Torres","lastName":"Silva","suffix":""},{"id":317430626,"identity":"0e1e9862-49c7-48b9-ac36-b7ce794e4fdf","order_by":3,"name":"Marcelo Lourenço Silva","email":"","orcid":"","institution":"Neuromodulação e Estudos da Dor (LANNED) - Universidade Federal de Alfenas","correspondingAuthor":false,"prefix":"","firstName":"Marcelo","middleName":"Lourenço","lastName":"Silva","suffix":""},{"id":317430627,"identity":"16a8ffd7-c349-43e9-a4eb-e5094bc72898","order_by":4,"name":"José Brito","email":"","orcid":"","institution":"Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health \u0026 Science","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"","lastName":"Brito","suffix":""},{"id":317430628,"identity":"613762b4-6ae6-4b54-9556-6941ef7b9f90","order_by":5,"name":"César Ferreira Amorim","email":"","orcid":"","institution":"Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health \u0026 Science","correspondingAuthor":false,"prefix":"","firstName":"César","middleName":"Ferreira","lastName":"Amorim","suffix":""},{"id":317430629,"identity":"4d2bc2d7-3e81-435d-84d0-ce9ed9448725","order_by":6,"name":"André Júdice","email":"","orcid":"","institution":"Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health \u0026 Science","correspondingAuthor":false,"prefix":"","firstName":"André","middleName":"","lastName":"Júdice","suffix":""},{"id":317430630,"identity":"7b59db1c-adda-490d-ada1-25a0ff6d7f15","order_by":7,"name":"José João Mendes","email":"","orcid":"","institution":"Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health \u0026 Science","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"João","lastName":"Mendes","suffix":""},{"id":317430631,"identity":"8312a108-fa6e-4287-9357-6f226908080e","order_by":8,"name":"Vanessa Machado","email":"","orcid":"","institution":"Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health \u0026 Science","correspondingAuthor":false,"prefix":"","firstName":"Vanessa","middleName":"","lastName":"Machado","suffix":""},{"id":317430632,"identity":"4c907fb7-5fff-4a21-bebe-44895265d0b9","order_by":9,"name":"João Botelho","email":"","orcid":"","institution":"Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health \u0026 Science","correspondingAuthor":false,"prefix":"","firstName":"João","middleName":"","lastName":"Botelho","suffix":""}],"badges":[],"createdAt":"2024-06-19 15:51:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4607026/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4607026/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60601147,"identity":"a2c9e1c4-1d56-4e41-a6a5-25fa70776687","added_by":"auto","created_at":"2024-07-18 16:04:13","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":137348,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between Bite force (here named in x-axis as Bite) with Right Handgrip Maximum Strength (RMGrip), Left Handgrip Maximum Strength (LMGrip), Right Handgrip Average Strength \u0026nbsp;(RAGrip) and Left Handgrip Average Strength (LAGrip).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4607026/v1/4c9e7a17b8ea06aabd864e61.jpeg"},{"id":61973889,"identity":"39c134a9-9cac-4033-bef4-2c3be88d9fd3","added_by":"auto","created_at":"2024-08-07 17:46:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":815527,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4607026/v1/dc91ecb8-cf28-44f6-84be-08e7860b4a8a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring bite force as an indicator of frailty phenotype: a pilot study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAgeing population has gained prominence because of its rapid and extensive occurrence. This situation presents significant challenges in obtaining resources to implement public policies promoting active ageing and addressing common multiple comorbidities within populations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These health issues contribute to the development of geriatric syndromes, which in turn can hinder the autonomy and independence of the elderly, known as frailty (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This can result in disability, vulnerability, institutionalisation, and ultimately, an earlier than expected death (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Recognizing groups of vulnerabilities and limitations can help identify frailty, a clinical syndrome characterised by the presence of three or more of the following criteria: involuntary weight loss (of 4.5 kilograms or more in the previous year), self-reported exhaustion, weakness indicated by grip strength, slow walking speed and levels low levels of physical activity (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrailty is closely associated with greater vulnerability to negative health consequences and greater susceptibility to adverse physical outcomes, especially in elderly populations. While the frailty-aging axis is not necessarily a direct result of the natural process \u003cem\u003eper se\u003c/em\u003e, it remains a significant factor to consider (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Several criteria have been presented to identify frailty, and can also be assessed by the accumulation of physiological and/or functional deficits (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These characteristics are causes and consequences of the accumulation of subclinical conditions, acute or chronic. The connection between frailty and several phenotypes, such as muscle weakness, bone fragility, low body mass index, increased risk of falls, susceptibility to trauma, heightened risk of infections, fluctuating blood pressure, and varying extents of physical capability impairment, is widely acknowledged. (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs a syndrome targeting all systems in the body, frailty and oral health have been studied by Miura et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), using physical measures (bite strength), with an emphasis on specific data obtained using the Dental Prescale system (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In their results, bite force was found to vary in healthy elderly people, with men having greater strength. In addition, frail elderly people were reported to show a significantly lower bite force compared to their healthy counterparts, and correlated with the number of teeth present. Expectedly, the same group suggested considering guidelines to improve chewing and oral health care should increase in the future (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The intriguing outcomes of this study lay the groundwork for the potential usefulness of biteforce in detecting frailty. Yet, its correlation with hand grip, a standard measure of comparable frailty indicators, has not been investigated before. Exploring this correlation could bolster the potential of biteforce as a diagnostic tool for frailty. Using a sample of elderly people, we aimed to explore whether bite force correlates with measures of grip strength.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Design and Setting\u003c/h2\u003e \u003cp\u003eThis cross-sectional study follows the recommendations of the case-control studies checklist of the Strengthening the Reporting of Observational studies in Epidemiology guideline (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This study was conducted at Egas Moniz School of Health and Science between January and May 2023. Elderly people attending campus clinics in Monte da Caparica (Almada, Portugal) were invited to participate in this study. This study was approved by the Ethics Committee of Egas Moniz (ID 1104/2022) and carried out according to the Helsinki declaration (as per its 2013 revision). Participants initially signed an informed consent form containing all information related to the study, including privacy and confidentiality terms, risks and benefits of the study, and possibility of withdrawing at any time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Eligibility Criteria\u003c/h2\u003e \u003cp\u003eTo be eligible, participants must had 60 years old or more, have functional teeth (at least 20 teeth) and present a state of cognition and oral functionality for independent individuals. Exclusion criteria include having more than 20 teeth lost by any reason, being completely toothless, having any clinical diagnosis of dementia-related neurological pathology.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Bite force measurement and protocol\u003c/h2\u003e \u003cp\u003eBite force was recorded using an electric dynamometer (EMG System \u0026reg;, S\u0026atilde;o Jos\u0026eacute; dos Campos, S\u0026atilde;o Paulo, Brazil). Participants were instructed through a demonstration were allowed to test the device one time before recording. Once fitted intra-orally, each participant remained seated and rested. They had a computer screen as biofeedback to monitor the result of the bite strength grading. Data collection was carried out in 3 full strength bite attempts lasting 10 seconds, with a 1-minute rest interval between each attempt (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The subjects seated in a chair without armrest, will feel fully resting on the floor, hips as far back in the chair as possible, and the hips and knee positioned at approximately 90\u0026deg;.\u003c/p\u003e \u003cp\u003eAdditional standardized instructions were given, using a pre-defined message in a card as follows: \"This test will tell me your maximum bite strength. When I say go, bite as hard as you can until I say stop. Before each attempt, I will ask, 'Are you Ready?\u0026rdquo; and then I will say \u0026lsquo;Go.\u0026rsquo; Stop immediately if you feel any unusual pain or discomfort at any time during the test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Handgrip measurements and protocol\u003c/h2\u003e \u003cp\u003eTo record the handgrip strength, we used the K-Grip-Link\u0026reg; (Kinvent Physio, Montpellier, France) and values collected were presented in Kg/F. The mechanical parts were properly sanitised and calibrated according to manufacturer's instructions. The elderly received information about the test and had a tablet screen as biofeedback to monitor the result of the strength measurement. Data collection was carried out in 3 series lasting 10 seconds, with a 1-minute rest interval, standardised by the K-Physio APP.\u003c/p\u003e \u003cp\u003eThe subjects seated in a chair without armrest, will feel fully resting on the floor, hips as far back in the chair as possible, and the hips and knee positioned at approximately 90\u0026deg;. Shoulder Adducted and neutrally rotated, elbow flexed to 90\u0026deg;, they should be in mid prone (neutral) and the Wrist Between 15\u0026ndash;30\u0026deg; of extension (dorsiflexion) and 0\u0026ndash;15\u0026deg; of ulnar deviation. The following instructions were made. \"This test will tell me your maximum grip strength. When I say go, squeeze as hard as you can until I say stop. Before each attempt, I will ask, 'Are you Ready?\u0026rdquo; and then I will say \u0026lsquo;Go.\u0026rsquo; Stop immediately if you feel any unusual pain or discomfort at any time during the test\u0026sup1;⁷.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Bioelectrical impedance analysis\u003c/h2\u003e \u003cp\u003eBody composition measurement was carried out using bioelectrical impedance analysis with the model ACCUNIQ BC310 (Korea). The software analyzed identity, height, age, sex, and body weight to produce an automatic report with the results of the Body Mass Index (BMI). Participants were assessed in the morning, after an overnight fast, and were instructed to abstain from physical exercise and stimulating beverages such as coffee or energy drinks for the last 24 hours before the measurement.\u003c/p\u003e \u003cp\u003eParticipants were instructed to remove all metallic objects, including earrings, rings, and belts, and to wear as little clothing as possible. They were then positioned barefoot and without socks on top of the scale, with their feet parallel, on top of the plantar sensors. The arms were positioned close to the body, holding the palm sensors, and it was necessary to press the start button with both thumbs simultaneously for approximately 10 seconds (factory default) to begin the measurement. Following the measurement, the elderly participants were assisted in getting off the scale and instructed to dress and wear shoes throughout the assessment (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Statistical Analysis\u003c/h2\u003e \u003cp\u003eThe degree of association between BITE and GRIP forces after removal of the effect of confounding variables was evaluated using partial correlation coefficients. To identify potential confounding variables of this association, Pearson's correlation coefficient was used after verification of the univariate normality of the variables involved, using the Shapiro-Wilk normality test. These statistical procedures were implemented with IBM 29.0 software (Armonk, New York), at a significance level of 5%.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Participants characteristics\u003c/h2\u003e \u003cp\u003eFifty-nine participants completed this exploratory clinical study, without exclusions. Overall, the mean age was 77.6 years (\u0026plusmn;\u0026thinsp;9.5) and were mostly women (70.0%, n\u0026thinsp;=\u0026thinsp;43) and 37.3% were institutionalised (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\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\u003eCharacteristics of participants\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=\"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 \u003cdiv align=\"left\" 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\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMales (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemales (n\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164.1 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e153.7 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e156.5 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.1 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66.4 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e68.8 (13.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.8 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.3 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28.2 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.2 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.8 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMGrip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.8 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLMGrip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.7 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.7 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.6 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRAGrip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.9 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.9 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAGrip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.7 (5.6)\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\u003eBMI - Body Mass Index, Bite - Bite Maximum Strength, RMGrip - Right Handgrip Maximum Strength, LMGrip - Left Handgrip Maximum Strength, RAGrip - Right Handgrip Average Strength, LAGrip - Left Handgrip Average Strength.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Biteforce and hand grip\u003c/h2\u003e \u003cp\u003eBefore assessing the association between bite and grip forces, we explored age and BMI as potential confounding variables. We applied the Pearson's correlation coefficient after checking the univariate normality of the variables involved (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Age was significantly correlated with bite and grip forces (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while BMI only correlated with handgrip forces but not bite force (coefficient= -0.047, p\u0026thinsp;=\u0026thinsp;0.737).\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\u003eCorrelations unadjusted between Age, BMI, bite force and handgrip strength.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBITE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRMGrip\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLMGrip\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRAGrip\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.329\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBITE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-0.321\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e-0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.737\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eRMGrip\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-0.340\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.316\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.448\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLMGrip\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-0.414\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.295\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.497\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.911\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eRAGrip\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-0.387\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.347\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.447\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.979\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.904\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLAGrip\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-0.424\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.290\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.496\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.894\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.993\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.895\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e59\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*. Correlation is significant at the 0.05 level (2-tailed).\u003c/p\u003e \u003cp\u003e**. Correlation is significant at the 0.01 level (2-tailed).\u003c/p\u003e \u003cp\u003eUnder these conditions, the partial correlations between the BITE and GRIP forces were calculated, controlling simultaneously for age and body mass index, with the results shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003eCorrelations adjusted for Age and BMI\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eControl Variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBITE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRMGrip\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLMGrip\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRAGrip\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLAGrip\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"14\" rowspan=\"15\"\u003e \u003cp\u003e\u003cb\u003eAge \u0026amp; BMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBITE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eRMGrip\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.441\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLMGrip\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.469\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eRAGrip\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.437\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLAGrip\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.464\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.881\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.878\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that, after controlling for potential confounding effects due to age and body composition, bite force (BITE) and handgrip force (GRIP) show significant positive correlations. It should be noted that the partial correlation coefficients in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e differ very little from the zero-order correlation coefficients presented in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which suggests that the effects of age and BMI on these correlations are not very relevant.\u003c/p\u003e \u003cp\u003eIn summary, there are positive and significant correlations between BITE and GRIP forces, which means that increases (decreases) in bite force values are accompanied by increases (decreases) in handgrip force values.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this exploratory study, the measurement of handgrip strength, a recognised frailty phenotype, was significant correlated with bite force in the elderly, even when adjusted for age and body mass index. The findings of this preliminary study lend to support bite force measurement as a valuable measure for assessing frailty in the elderly. This association is particularly noteworthy given its potential impact on the practical application of this test, which, like the handgrip protocol, is a rapid and straightforward procedure (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnilateral handgrip strength is considered a gold-standard protocol for identifying the risk of frailty and mobility limitations in the elderly, but its defined cut-off points vary according to sex and BMI (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Sallinen et al. carried out a Finnish population-based health survey to determine the optimal cut points in handgrip strength measurement, and explored whether these cut points would be BMI-dependent (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Overall, hand-grip strength cut points were reported to increase along with increasing BMI in men but remained equivalent in women at 21 kg. Alas, regardless of sex, when handgrip strength underperformed below the specific BMI cut-off values, participants showed three times higher risk to have mobility limitation. Yet, subsequent research demonstrated this relationship between BMI and handgrip strength in the elderly is still controversial (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). With this controversy in mind, our results show that biteforce seems to be independent on BMI, but this requires confirmation with larger and prospective cohorts to determine cut offs and to test its performance.\u003c/p\u003e \u003cp\u003eErgo, our data suggests that this type of assessment show potential for clinical use as a criterion (phenotype) for frailty, providing a further argument for discussion on this issue. This goes in line with Iwasaki et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) where maximum bite force correlated with an increased risk of frailty in the elderly in a prospective cohort of Japanese elders. Following up 322 participants for 5 years, this study explored whether poor oral function, as indicated by low maximum bite force would link to higher risk of developing frailty among elderly men and women. About 15.2 percent of participants developed frailty and the lower tertile of maximum bite force was associated with three times the risk of developing a frailty phenotype (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall, our preliminary data validate the methodological applicability of biteforce and its correlation with a standard criterion of frailty. We reported this study following the PRISMA guideline which increases the transparency and future replicability. Yet, this study presents shortcomings worth discussing, such as the limited sample of this pilot study. The observational nature of this study precludes any causal relationship and defining robust cut off values.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBite force showed a moderate correlation with hand grip strength measurements, showing potential as a frailty diagnostic criterion. Future studies shall explore the validity of these preliminary findings in larger samples to understand whether bite force might be useful in the prediction of elderly frailty risk and to define cut off values.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interests Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT author statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLuciano Maia:\u003c/strong\u003e Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing - original draft; Writing - review \u0026amp; editing.\u0026nbsp;\u003cstrong\u003eRobson Dias Scoz\u003c/strong\u003e: Methodology; Resources; Software; Writing - original draft; Writing - review \u0026amp; editing. \u003cstrong\u003eJosie Resende Torres da Silva\u003c/strong\u003e: Writing - review \u0026amp; editing. \u003cstrong\u003eMarcelo Louren\u0026ccedil;o da Silva\u003c/strong\u003e: Writing - review \u0026amp; editing. \u003cstrong\u003eJos\u0026eacute; Brito\u003c/strong\u003e: Formal analysis; Writing - review \u0026amp; editing. \u003cstrong\u003eC\u0026eacute;sar Ferreira Amorim\u003c/strong\u003e: Writing - review \u0026amp; editing. \u003cstrong\u003eAndr\u0026eacute; J\u0026uacute;dice\u003c/strong\u003e: Writing - review \u0026amp; editing. \u003cstrong\u003eJos\u0026eacute; Jo\u0026atilde;o Mendes\u003c/strong\u003e\u003cem\u003e:\u003c/em\u003e Supervision, Writing- Reviewing and Editing.\u003cstrong\u003e\u0026nbsp;Vanessa Machado\u003c/strong\u003e: curation; Formal analysis; Investigation; Methodology; Writing- Reviewing and Editing. \u003cstrong\u003eJo\u0026atilde;o Botelho:\u003c/strong\u003e Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Writing - original draft; Writing - review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge the support by Sausport in providing material for this project and to FCT/MCTES for the financial support to CiiEM (UIDB/04585/2020) through national funds.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLeng S, Chen X, Mao G. Frailty syndrome: an overview. CIA mar\u0026ccedil;o de 2014;433.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoman-Liu D. Age-related changes in the range and velocity of postural sway. Archives Gerontol Geriatr julho de. 2018;77:68\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCiosak SI, Braz E, Costa MFBNA, Nakano NGR, Rodrigues J, Alencar RA, et al. Senesc\u0026ecirc;ncia e senilidade: novo paradigma na aten\u0026ccedil;\u0026atilde;o b\u0026aacute;sica de sa\u0026uacute;de. Rev esc enferm USP dezembro de. 2011;45(spe2):1763\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc. junho de. 2006;54(6):991\u0026ndash;1001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFried LP, Cohen AA, Xue QL, Walston J, Bandeen-Roche K, Varadhan R. The physical frailty syndrome as a transition from homeostatic symphony to cacophony. Nat Aging 14 de janeiro de. 2021;1(1):36\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 1 de mar\u0026ccedil;o de. 2001;56(3):M146\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 30 de agosto de. 2005;173(5):489\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc maio de. 2007;55(5):780\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantos RCD, Menezes RMPD, Ara\u0026uacute;jo GKND, Marcolino EDC, Xavier AG, Gon\u0026ccedil;alves RG et al. S\u0026iacute;ndrome da fragilidade e fatores associados em idosos no pronto atendimento. Acta Paulista de Enfermagem. 1 de junho de 2020;33:eAPE20190159.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB, Walston JD, et al. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc abril de. 2004;52(4):625\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiura H, Watanabe S, Isogai E, Miura K. Comparison of maximum bite force and dentate status between healthy and frail elderly persons. J Oral Rehabilitation junho de. 2001;28(6):592\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManzon L, Vozza I, Poli O. Bite Force in Elderly with Full Natural Dentition and Different Rehabilitation Prosthesis. Int J Environ Res Public Health. 3 de fevereiro de 2021;18(4):1424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol abril de. 2008;61(4):344\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelencz CA, Mu\u0026ntilde;oz ISS, Amorim CF, Nicolau RA. Effect of Low-Power Gallium\u0026ndash;Aluminum\u0026ndash;Arsenium Noncoherent Light (640 nm) on Muscle Activity: A Clinical Study. Photomedicine and Laser Surgery. outubro de. 2010;28(5):647\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang SW, Kim TH, Choi HM. The reproducibility and validity verification for body composition measuring devices using bioelectrical impedance analysis in Korean adults. J Exerc Rehabil agosto de. 2018;14(4):621\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSousa-Santos AR, Amaral TF. Differences in handgrip strength protocols to identify sarcopenia and frailty - a systematic review. BMC Geriatr dezembro de. 2017;17(1):238.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSallinen J, Stenholm S, Rantanen T, Heli\u0026ouml;vaara M, Sainio P, Koskinen S. Hand-grip strength cut points to screen older persons at risk for mobility limitation. J Am Geriatr Soc setembro de. 2010;58(9):1721\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoraya N, Parwanto E. The Controversial Relationship between Body Mass Index and Handgrip Strength in the Elderly: An Overview. Malays J Med Sci junho de. 2023;30(3):73\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIwasaki M, Yoshihara A, Sato N, Sato M, Minagawa K, Shimada M, et al. A 5-year longitudinal study of association of maximum bite force with development of frailty in community‐dwelling older adults. J Oral Rehabilitation janeiro de. 2018;45(1):17\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bite force, Hand grip, Frailty, Oral health, Phenotype","lastPublishedDoi":"10.21203/rs.3.rs-4607026/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4607026/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThe aim of the study was to explore the correlation between bite force and grip strength as measures of frailty in the elderly.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eElderly people completed a socio-demographic questionnaire, protocols for measuring bite force, handgrip strength using dynamometry and body composition analysis using electrical bioimpedance. Statistical analyses were carried out to assess the association between these variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e We assessed 59 participants. The results indicate a positive correlation between bite force and grip strength, even after controlling for age and body mass index (BMI). There are positive and significant correlations between BITE and GRIP forces, which means that increases (decreases) in bite force values are accompanied by increases (decreases) in handgrip force values.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur results suggest that decreased bite strength may increase the risk of frailty over time. In conclusion, the study suggests that bite force can serve as a useful indicator of frailty risk in the elderly and calls for further research to validate these initial results in larger samples. This correlation emphasises the importance of oral health in the care of the elderly and in frailty prevention strategies.\u003c/p\u003e","manuscriptTitle":"Exploring bite force as an indicator of frailty phenotype: a pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 16:04:08","doi":"10.21203/rs.3.rs-4607026/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a324187a-d3f8-4aa3-b359-73fd939f75d2","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-07T17:38:48+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 16:04:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4607026","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4607026","identity":"rs-4607026","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}