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IDDSI

The International Dysphagia Diet Standardisation Initiation is here and being utilized in many facilities.

IDDSI was created to replace the National Dysphagia Diet and to standardize food and liquid consistencies.

I’m sure you have probably been in a number of facilities that interpret Mechanical Soft, Dysphagia Soft, etc a little different than other facilities.   Some facilities allow a number of food items on one diet level that another facility adds into a different level.

IDDSI

IDDSI involves 5 food consistency levels and 5 liquid levels.

So what do these levels mean?

Level 0 (Thin) is a liquid that flows like water.   (Flow test 1 ml or less in the syringe.)

Level 1 (Slightly Thick) Thicker than water, but is not quite Mildly Thick (formerly Nectar Thick).   (Flow test 1-4 ml remains in syringe).   This may include formula or commercially available nutrition drinks such as Boost or Ensure.

Level 2 (Mildly Thick formerly Nectar Thick).   Flows off a spoon but is thicker than water.   Requires increased effort to drink from a straw.   (Flow test 4-8 ml left in the syringe.)

Level 3 (Moderately Thick formerly Honey Thick).  This level takes a moderate effort to drink through a straw, but can be drunk from a cup.   This level can be taken from a spoon, but is too thin for a fork.   (Flow test 8-10 ml left in the syringe.)

Level 4 (Pureed/Extremely Thick formerly Pudding Thick).  Usually can be administered via spoon, however may also be eaten via fork.  Cannot be taken through a straw, usually taken via spoon.   There should be no lumps, requires no chewing and the liquid should not separate.   (Flow Test 10 ml remains in the syringe.)   Spoon tilt test-should fall off the spoon in single spoonful.   Should sit in a mound on top of the spoon/fork with minimal dripping through the fork.

Level 5 (Minced and Moist) Small lumps in the bolus (no larger than 4mm width and 15mm length for adults), can be eaten using spoon or fork.   Liquid should not separate from food.   (Fork test minimal pressure to mash with no blanching of the thumbnail  to white while pressing.)  (Spoon test should fall off the spoon in a cohesive mound with little to none left on the spoon.)

Level 6 (Soft and Bite Sized) Can be eaten with a fork, spoon or chopsticks.   Each piece should be no larger than 15mm.   Chewing is required with this consistency, however biting or cutting is not required.   (Fork test, when a fork is pressed against the food, the thumbnail should blanch or turn white to squash or break apart the food).   (Spoon test pressure from the spoon can cut, squish, mash or break apart the food and it will not return to its shape.)

Level 7 (Easy to Chew) Normal, everyday soft foods.   Size of food is not restricted.   Requires the ability to bite/chew food.   (Fork/Spoon Test food is easily cut with pressure from a fork/spoon, thumbnail blanches or turns white when applying pressure to the food until it smashes, breaks apart or crumbles without resuming its original shape.

Level 7 (Regular) Normal, everyday food.

Transitional Foods (Fork/Spoon test, add 1 ml water, wait 1 minute, when applying pressure on the fork/spoon on the food, thumbnail blanches while applying pressure until the food breaks or smashes.)

Some examples of transitional foods?

Ice chips
Ice cream/Sherbet if assessed as suitable by a Dysphagia specialist
Japanese Dysphagia Training Jelly sliced 1 mm x 15 mm
Wafers (also includes Religious Communion wafer)
Waffle cones used to hold ice cream
Some biscuits/ cookies/ crackers
Some potato crisps – only ones made or formed from mashed potato (e.g. Pringles)
Shortbread
Prawn crisps
Veggie Stix™
Cheeto Puffs™
Rice Puffs™
Baby Mum Mums™
Gerber Graduate Puffs™

For everything you need to know regarding IDDSI, visit the website here.

Do you want easily printable information sheets for each level and testing for each level?    Find that here.

Want samples and examples for testing liquids/foods?   Find that here.

Evidence supporting IDDSI can be found here.

IDDSI documentation has been translated in multiple languages that you can download here.

Available languages:

  • Chinese
  • Farsi
  • French
  • German
  • Greek
  • Italian
  • Norwegian
  • Portuguese
  • Spanish
  • Swahili

Need help with implementation of IDDSI into your facility?   You can download documents here.

 

 

 

Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.

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The SLP and the Dining Room

 

My dining room story….

I can’t even count how many times I have started work in a new building or started a new PRN job and been told meal times so that I can go sit with patients during their meals for their therapy time.  It’s easy, right.  I go sit in the dining room and “observe” 8 patients for signs and symptoms of dysphagia that I’ve already identified and remind patient a to use a chin tuck and patient b to eat at a slower pace.

The reality

This is how I learned dysphagia therapy.  What was taught to me was to sit with them during the meal to work on trials, observe those trials and remind them to use their strategies.  The reality:  I tried to do my “job” however Mrs. Smith needed more coffee, could I be a dear and run Mrs. Brooks to the bathroom?  I could never do my “job” because I was a waitress.  With no tips.

Not only could I not do my “job”, I was not doing anything for those patients!  That is not rehabilitation.  Look at it this way, if we never stress the system and remain at status quo, how will it improve?  If I’m trying to run a 5k, I’m going to push myself to keep going a little further.  If I continue to run around the block, I will never build the strength and endurance for a longer run.  If we never challenge the swallowing system with a more difficult bolus, then how will my patient upgrade their diet.

Therapy should be…..

Therapy should not be in the dining room.  Just like I don’t want a physical therapist to show up in the middle of my meal, our patients don’t want us popping in at their meal time and “working” with them.

Remember, swallowing is a sub-maximal muscle activity.  When swallowing, the patient does not use their swallowing muscles to the fullest extent.   There may be times that you need to observe and assess a patient but seriously, that shouldn’t happen multiples times a week for multiple weeks.

How is the patient supposed to progress with the therapy if there is never any education, home exercise program or just plain working with the patient.

Let’s challenge our patients and stop just observing!

Reference

Logemann, J. A. (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-ed.

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Cervical Auscultation

 

What is Cervical Auscultation?

Using Cervical Auscultation (CA) involves the use of a stethoscope, placed on the throat to “listen” to the sounds of the swallow.

Clinicians often use CA to assess swallow sounds and airway sounds.  Judgements are made on the normality of the swallow or the degree of impairment of swallowing.

Cervical Auscultation and Swallowing

In theory, “there are specific sounds related to events of the swallow.”   Some clinicians indicate that a swoosh, a click or a clunk can indicate physiologic events such as premature spillage, aspiration, laryngeal vestibule closure, penetration, etc.

Many clinicians swear by cervical auscultation, even replacing imaging with auscultation.

There is also an argument that there is no evidence on what causes swallowing sounds or whether these sounds correspond to physiological swallowing events.

The evidence tells us that CA may not be all it’s cracked up to be.

What does the Evidence Tell Us? 

A systematic review of cervical auscultation by Legarde et al 2016, reviewed 90 articles.  Using inclusion and exclusion criteria 6 articles were included in the review as the other articles did not meet criteria to be included.   (Full article can be accessed at the link below.)

The review found that the reliability of Cervical Auscultation is insufficient to be used as a stand-alone tool in dysphagia in adults.  There is no evidence of reliability or validity in Cervical Auscultation in the pediatric population.   Cervical Auscultation should not be used as a stand-alone tool in the diagnosis of dysphagia.

When CA was synchronized with endoscopy (Leslie, et al, 2007), they found that there was a wide-spread degree of the timing of swallowing sounds and physiologic events.  No individual sounds was consistently associated with any physiologic event.  There was no link between:

  • Pre-Click and onset of apnea
  • Pre-Click and the start of epiglottic excursion
  • Click and the epiglottis returning to rest
  • Click and the end of swallow apnea

They also found that the absence of a swallowing sound was not a sign of pathologic swallowing but that a repeated abnormal pattern may indicate an impairment.

In conclusion there is no robust evidence to support CA in dysphagia and judgement between SLP interpretation of sounds or absence of sound was poor.

Do You have an Opinion?

What do you think?  Are you for or against CA?  Maybe you have no opinion either way.  Let me know in the comments!

References:   

Lagarde, M. L., Kamalski, D. M., & Van Den Engel-Hoek, L. E. N. I. E. (2016). The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review. Clinical rehabilitation30(2), 199-207.

Dudik, J. M., Coyle, J. L., & Sejdić, E. (2015). Dysphagia screening: Contributions of cervical auscultation signals and modern signal-processing techniques. IEEE transactions on human-machine systems45(4), 465-477.Leslie, P., Drinnan, M. J., Zammit-Maempel, I., Coyle, J. L., Ford, G. A., & Wilson, J. A. (2007). Cervical auscultation synchronized with images from endoscopy swallow evaluations. Dysphagia22(4), 290-298.

Leslie, P., Drinnan, M. J., Zammit-Maempel, I., Coyle, J. L., Ford, G. A., & Wilson, J. A. (2007). Cervical auscultation synchronized with images from endoscopy swallow evaluations. Dysphagia22(4), 290-298.

Leslie, P., Drinnan, M. J., Finn, P., Ford, G. A., & Wilson, J. A. (2004). Reliability and validity of cervical auscultation: a controlled comparison using videofluoroscopy. Dysphagia19(4), 231-240.

Borr, C., Hielscher-Fastabend, M., & Lücking, A. (2007). Reliability and validity of cervical auscultation. Dysphagia22(3), 225-234.

Stroud, A. E., Lawrie, B. W., & Wiles, C. M. (2002). Inter and intra-rater reliability of cervical auscultation to detect aspiration in patients with dysphagia. Clinical rehabilitation16(6), 640-645.

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What Would You Do?

I would love to share a story with you. 

Now keep in mind, I’ve been an SLP for a lot of years and feel that I do a pretty good job.   Sometimes, I may even get a little over-confident in my skills and have to examine what I’m doing.

Let’s talk about a patient I’ve had.   All identifying information will be withheld. 

This person was referred after a family member was concerned with increased choking with food and drinks.   This patient has a history of dysphagia, which had resolved. 

I get the call to go in and go in prepared for an evaluation. I did everything I would normally do in an evaluation.

I did a cranial nerve exam which all the cranial nerves seem to be intact. I had the person eat and drink while I observed. I even palpated the larynx to see what I could feel. Everything seemed to be quite normal.

I have to do vitals for home health so I went ahead and got out my pulse oximeter to see if there is any change in the person’s sats. They were able to drink some water with no change in 02 saturation.

Everything seemed to check out pretty well however the family was still very concerned, so just to cover my bases and to make sure that I hadn’t missed something I requested a modified barium swallow study.

Now imagine my surprise when I get the report for that swallow study and find out that this person’s actually aspirating multiple consistencies.

The person has timing issues with laryngeal elevation and closure and with oral containment prior to the swallow.

I mean really how can that be?

There was no change in O2 sats for me. The larynx felt like it was moving pretty well. Cranial nerves seem to be intact and functioning.

Where did I go wrong?

I didn’t. I realized my limitation without visualization. I have read my research and know that O2 sats and palpation is not always accurate.

I did right by my patient and pushed for instrumental exams.

I had push-back at first. Do you really need an instrumental? Can’t you just treat? When I told the company I need the instrumentals or I’m referring patients to another company, they started approving my requests.

Do right by your patients.

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“Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes”

 

If you are considering joining or starting a head and neck cancer program, this is the read for you!

I was searching through articles this morning and found this very article stating the importance of a team approach and a systematic approach to head and neck cancer!

“Head and neck cancer guidelines recommend multidisciplinary team monitoring and early intervention.”

Prophylactic treatment for head and neck cancer has been found to increase maintenance of tongue muscle mass, preserve some taste and have an overall improved swallow.   The SLP should be right in there, from the beginning to determine baseline swallowing function and to provide education for what may happen to the swallow.

“We need patient care using a systematic approach for head and neck cancer.”

Read the research.  Keep up with the new approaches and utilize them in  your therapy.  Dysphagia assessment and treatment approaches are ever-evolving and you have to stay current to provide your patients with the best care possible.

With the multidisciplinary Approach:

  • Improved outcomes
  • Better survival rates
  • Maximize results through use of a coordinated pathway
  • Increase efficiency in care delivery
  • Reduce cost
  • Shorten the length of the hospital stay
  • Improve overall patient outcomes

Who should/may be on the multidisciplinary team:

  • Head and Neck Surgeon
  • Medical Oncologist
  • Radiation Oncologist
  • Nursing
  • Speech Language Pathologist
  • Dietician
  • Social Worker
  • Administrative Professionals (Systems Analyst, Clinical Research Coordinator)

“A significant impact of Head and Neck Cancer is typically the impact on swallowing and inadequate nutritional intake.”

The SLP plays a vital role in the assessment and treatment of swallowing.

“Prophylactic and ongoing Speech Language Pathology services can be vital by impacting swallow function, nutritional status and overall quality of life.”

We’re not just one and done.  Even though the patient may not initially have difficulty with swallowing early in their treatment doesn’t mean it will never happen.   You need to check up on the patients throughout their course of treatment and even after their treatment to continue to assess the impact on swallowing.

Collecting Data:

Patients undergo a pre-treatment MBSS (Modified Barium Swallow Study) and/or FEES (Flexible Endoscopic Evaluation of Swallowing).  Also completed with patients:

Prophylactic Exercises Included:

  • Lingual strengthening
  • Masako Maneuver
  • Effortful or Supraglottic Swallow
  • Mendelsohn Maneuver
  • Shaker
  • Therabite (incisal opening less than 40mm)
  • EMST (increase airway clearance/protection)

*Exercises completed 2x/day, 6 days/week

References:

Dance Head and Neck Clinical Pathway (D-HNCP)

Messing, B. P., Ward, E. C., Lazarus, C., Ryniak, K., Kim, M., Silinonte, J., … & Sobel, R. (2019). Establishing a multidisciplinary head and neck clinical pathway: An implementation evaluation and audit of dysphagia-related services and outcomes. Dysphagia34(1), 89-104.

 

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They won’t follow my recommendations so let’s burn them at the stake!!

OK, so we’re probably not going to be burning any patients at the stake. I’m fairly certain that you may lose your license for that!

I’m sure we’ve all been there though.  We do a thorough assessment of a patient.   We obtain instrumental assessment just as we were advised.  We make recommendations based on the assessment and instrumental assessment. Then the patient decides they don’t want to follow those recommendations. They decide that they don’t care for the thick liquids and they’re just going to drink regular liquids. So then what do you do with this immaculate plan of care that you’ve taken hours to write.

Some People say that if patients don’t follow recommendations then we need to educate the patient and discharge them due to noncompliance.

Why would you discharge a patient because they don’t follow your recommendation? Isn’t this the person that probably needs your help more than any other?

So think about this scenario. You go to the doctor and find you put on a few extra pounds.   The doctor may recommend that maybe you need to add exercise to your day. Your first thought is sure pal where do you think I’m going to add this exercise into my day? Before I start waking the kids to hours before they actually have to be up so that I can get them out of bed?  Should I add it in at the end of my day after I worked a full time job to go to my PRN job(s) and then to cheer on my kids in whatever sporting events they might be participating this season?  Maybe you don’t understand what I do and how busy I am and I’m top of everything else I have to do at home and at work, I’m expected to keep up with journal articles and best practices. So you tell me when I’m going to add exercise into that day and still have time to sleep at night.  You probably don’t say that.   You may think it as you tell the doctor you’ll do your best try to get a little more exercise.

You go back to the doctor and you’ve only exercised a couple of days in the last four weeks. Now how would you feel if your doctor then said, you know, you haven’t done what I’ve asked you to do and if you continue this lifestyle you are going to end up with high cholesterol, high blood pressure, diabetes, or a number of other conditions. So since you are not following my recommendations, I’m going to sign off on you as a non compliant patient.

Now think of this patient that has possibly had some life altering issue. Maybe they’ve had a stroke or maybe they were recently diagnosed with Parkinson’s disease and all of a sudden have a swallowing problem.  In walks Susie SLP who says everything you eat and drink is going down into your lungs so what I’m going to need you to do is put this delicious thickener in your drinks and then purée all your food.   If you don’t do this, you can aspirate, develop pneumonia and possibly die.   

Some patients try.   They really do. Like you tried that new diet that eliminated all sugar. You did really well until somebody brought in a cake that was just a little too tempting. It’s the same thing for patients. They see other people eating during commercials on TV for whatever restaurant is seen being advertised. They try the thickener in their drinks and say heck with this I’ll take my chances with pneumonia.

The bottom line is, the patient is the one that makes the final decision. Our license and our CCC allows everyone know that we have completed the requirements to practice speech language pathology in each state or in a given facility. Our license does not state that we are now food police and have to monitor every item that goes into our patient’s mouth. If we make recommendations that are ethical and driven by best practice for our patient why would anybody take away our license because the patient decided to not follow all of our recommendations.

Document document document.

Educate educate educate.

Have a conversation with your patient and explain to them why you made the recommendation and what is going on. Educate on oral care and compensation if tested and effective during instrumental assessment.    Let the patient decide on their plan of care with you and the care team.   Maybe the decision is to not follow diet recommendations but to follow a plan for oral care and rehabilitation for the swallow.   

Stay tuned to more information on why your patient may refuse!   

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Carbonated Beverages

Carbonation

Not Nectar Thick

When patients have dysphagia, often sensory techniques, including carbonation can help increase aspects of the swallow.  For some reason, at one point in time, the research was translated to substitution of carbonated beverages, including soda to replace nectar thick liquids.

 

carbonated

Continue reading Carbonated Beverages

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The Patient Exercising Their Right to Choose (Formerly The Non Compliant Patient)

 

EDIT 1/4/17.  Due to a recent Facebook post, I wanted to change some wording on this post.  As with all areas of dysphagia, I continue to grow, learn and change my beliefs, mainly because of the patients I serve.

Although my belief stands that those patients who do not follow my recommendation continue to require SLP services, maybe we should look at these patients not as “non-compliant” but as “exercising their right to choose.”  

There was post recently on the Special Interest Group (SIG) 13 email blast.  An SLP was asking what to do with a noncompliant patient.

When I was first beginning of the ever-changing world of speech pathology, I first learned that if a patient is noncompliant then they are discharged.  The rationale was, a doctor would release a patient for noncompliance and our license is always at stake.

My belief system is not the same, fortunately for my patients!

First, think about this.  Aren’t the noncompliant patients who choose to not follow the SLP’s recommends the ones we should be the most concerned about?  The patients that are compliant are on a modified diet that has been determined to be the safest diet consistency for them, although there is always some risk with every recommendation we make.  They may be regulated by caregivers or a facility, but if they are following all instructions and diet recommendations, they should be safe.  The noncompliant patient who aspirates thin liquids, but continues to drink them is the one you should be the most concerned for their safety.  That is the patient that may be most at risk for aspiration pneumonia.

In my experience, patients are not compliant unless they are forced to be. I have worked with patients that will sneak a drink, sneak a bite whenever they have the opportunity.  I have had patients that were supposed to be on thickened liquids, went home, told me they were continuing the thickened liquids but were actually drinking all thin liquids.

The best thing we can do for our noncompliant patients is to educate and rehabilitate.  Why not make them safer with the consistency they choose?

The first thing I do with every patient that is cognitively able is teach them and/or their caregivers about oral care.  If you read anything about oral care and aspiration pneumonia, the take-home message should be that pneumonia is a result of the bacteria from the oral cavity traveling to the lungs through saliva or a liquid/food swallow.  I recently wrote a post about oral care which you can find here.

It’s important to remember that we want the patient to succeed with the diet they choose to consume.  We can recommend a safe diet and we can advise but we have to focus on the rehabilitation.  Just remember, not everybody that aspirates develops aspiration pneumonia.  There are functional aspirators.

You may have a patient that aspirates everything on the Modified Barium Swallow Study (MBSS), goes home and consumes a regular diet without ever having an aspiration event or a pneumonia.  Just because that patient does not choose the diet you recommend does not mean you give up on them.  If they are willing to put in the work and give you some time (they will have to buy-in to your program)  THOSE are absolutely  patients with whom we should work.

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Supraglottic and Super-Supraglottic Swallows and Tongue Pressure

keep-calm-and-hold-your-breath-67

Fujiwara, S, Ono, T, Minagi, Y, Fujiu-Kurachi, M, Hori, K, Maeda, Y, Boroumand, S, Nitschke, I, Ursula, V, Bohlender, J.  Effect of Supraglottic and Super-supraglottic swallows on Tongue Pressure Production against Hard Palate.  Dysphagia (2014) 29:655-662.  

The Super- and Supraglottic Swallows are maneuvers used to assist in early airway closure to prevent food or drink from being aspirated prior to the swallow.  

Participants:  19 healthy young staff members of the University of Zurich Dental School (13 females, 6 males) with an age range from 17-40.

Equipment:  Tongue pressure measurements were recorded using the Swallow Scan System using a pressure sensor that forms a “T” shape following the curve of the palate.  Participants were seated upright with their heads immobilized by  a head rest.  

Procedure:  This study looked at normal swallow, Supraglottic Swallow (ss) and Super-Supraglottic Swallow (sss).   Each participant swallowed 5 ml of water at room temperature.  For the SS, a syringe was used to inject 5 ml of water into the floor of the oral cavity with the instructions “breathe through your nose, then hold your breath lightly before and during swallowing.  Cough immediately after you finish swallowing.”  For the SSS the same procedure and instructions were given, plus the additional instruction to put the palms of their hands together in front of their chest and press them hard against each other while they held their breath.

Results:  The perimeters measured  were:  duration, maximal magnitude and integrated value of tongue pressure during swallowing.  “The duration of tongue pressure was significantly longer at the anterior-median part of the hard palate during both SS and SSS than with normal wet swallow.  The maximal magnitude increased significantly only at the posterior part of the hard palate during SS, but at all points during SSS.”  Not only do the SS and SSS increase protection of the airway prior to the swallow, they may also function to strengthen the tongue.  

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Variations in Tongue-Palate Pressures with Xanthan Gum Thickened Liquids

Steele, CM, Molfenter, SM, Peladeau-Pigeon, M, Polacco, RC, Yee, C.  Variations in Tongue-Palate Swallowing Pressures When Swallowing Xanthan Gum-Thickened Liquids.  Dysphagia (2014) 29:678-684.

“Thickened liquids are frequently recommended to reduce the risk of aspiration in patients with oropharyngeal dysphagia.”  We know that tongue-palate pressures increase with thicker liquids, however little is known about the differences in swallowing pressures with nectar and honey thick liquids.

“Liquid boluses are initially held in a chamber along the midline groove of the tongue.  The tongue moves upwards and forwards, compressing a bolus against the palate and squeezing it backwards in a conveyer-belt like fashion.  As the bolus reaches the pharynx, the tongue withdraws from the palate, and sweeps downwards and backwards.” 

Participants:  78 healthy adults.  40 (19 men and 21 women) with a mean age of 27 and 38 (22 women and 16 men) with a mean age of 70.  No participants had a history of swallow, motor speech, gastro-esophageal or neurological difficulties.  

Equipment:  Lingual pressures were measured using the lingual manometry module of the KayPentax Swallowing Signals Lab.  Using a soft silicone strip with three pressure bulbs were placed in the palate and measurements were registered at the anterior, mid and posterior hard palate.  Participants took blocks of 4 repeated sips using flavored (lime, raspberry, diet raspberry or cranberry) water, nectar thick and honey thick liquids.  Sip size was not controlled and cups contained 60 ml of liquid.  The cup was instructed to be removed from the lips following each sip.  The xanthan thickener was supplied by Flavour Creations, Inc.  

Results:  Healthy adults do recruit higher tongue-palate pressure amplitudes with nectar and honey thick liquids using xanthan gum as compared to water.  The authors warn that “although thicker liquids elicit higher amplitudes of tongue-palate pressure compared to water, the observed values should still be easily achieved by most adults, falling below 40% of maximum isometric pressure values.”  It is also important to remember that although thickened liquids require higher tongue pressures to propel, caution is needed when selecting thickened liquids for patients with reduced tongue strength and that viscosity may become too thick to be effective for oral processing.

The authors also warn that there are limitations to the findings including:

  1. That the sweetness of the flavoring may have contributed to the observed pressure differences compared to the water.
  2. Sip volume was not controlled and the influence of the sip size on tongue pressures is unknown.
  3. Participants with dentures had to remove their top plates to avoid damage from glue from the sensors.
  4. Different thickening agents may encourage different results.

Tongue

I think this area will take an interesting turn with the amount of people getting their tongues pierced.  What are your thoughts?