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Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD)

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Newman, Roger, Vilardell, Natàlia, Clavé, Pere, Speyer, Renée·2016·Dysphagia
DOI 10.1007/s00455-016-9696-8PMC PMC4929168
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Abstract

Background: Fluid thickening is a well-established management strategy for oropharyngeal dysphagia (OD). However, the effects of thickening agents on the physiology of impaired swallow responses are not fully understood, and there is no agreement on the degree of bolus thickening. Aim: To review the literature and to produce a white paper of the European Society for Swallowing Disorders (ESSD) describing the evidence in the literature on the effect that bolus modification has upon the physiology, efficacy and safety of swallowing in adults with OD. Methods: A systematic search was performed using the electronic Pubmed and Embase databases. Articles in English available up to July 2015 were considered. The inclusion criteria swallowing studies on adults over 18 years of age; healthy people or patients with oropharyngeal dysphagia; bolus modification; effects of bolus modification on swallow safety (penetration/aspiration) and efficacy; and/or physiology and original articles written in English. The exclusion criteria consisted of oesophageal dysphagia and conference abstracts or presentations. The quality of the selected papers and the level of research evidence were assessed by standard quality assessments. Results: At the end of the selection process, 33 articles were considered. The quality of all included studies was assessed using systematic, reproducible, and quantitative tools (Kmet and NHMRC) concluding that all the selected articles reached a valid level of evidence. The literature search gathered data from various sources, ranging from double-blind randomised control trials to systematic reviews focused on changes occurring in swallowing physiology caused by thickened fluids. Main results suggest that increasing bolus viscosity (a) results in increased safety of swallowing, (b) also results in increased amounts of oral and/or pharyngeal residue which may result in post-swallow airway invasion, (c) impacts the physiology with increased lingual pressure patterns, no major changes in impaired airway protection mechanisms, and controversial effects on oral and pharyngeal transit time, hyoid displacements, onset of UOS opening and bolus velocity—with several articles suggesting the therapeutic effect of thickeners is also due to intrinsic bolus properties, (d) reduces palatability of thickened fluids and (e) correlates with increased risk of dehydration and decreased quality of life although the severity of dysphagia may be an confounding factor. Conclusions: The ESSD concludes that there is evidence for increasing viscosity to reduce the risk of airway invasion and that it is a valid management strategy for OD. However, new thickening agents should be developed to avoid the negative effects of increasing viscosity on residue, palatability, and treatment compliance. New randomised controlled trials should establish the optimal viscosity level for each phenotype of dysphagic patients and descriptors, terminology and viscosity measurements must be standardised. This white paper is the first step towards the development of a clinical guideline on bolus modification for patients with oropharyngeal dysphagia.

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  • Xanthan gum seems to be better than starch as a thickening agent.

    “xanthan gum seems to be better than starch”

    From ESPEN guideline on hospital nutrition (2021) · cites this paper as [191]

    The Results sections on palatability and rheology report that patients preferred gum-based drinks and that xanthan gum maintains viscosity more consistently than modified starch. But the Results section on swallowing assessment says the two agents showed no major or significant difference in swallowing safety, so the paper does not establish that xanthan gum is better overall. Page numbers were not supplied in our copy. (LLM, conf=0.86)

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Authors
Newman, R., Vilardell, N., Clavé, P., & Speyer, R.
Affiliations
  • James Cook University (AU)
  • Universitat Autònoma de Barcelona (ES)
  • Leiden University Medical Center (NL)
ORCID
Venue
Dysphagia
Publisher
Springer Science and Business Media LLC
Published
2016-03-25
Volume
31
Issue
2
Pages
232-249
ISSN
  • 0179-051X (ISSN-L)
  • 1432-0460
DOI
10.1007/s00455-016-9696-8
PMC
PMC4929168
OpenAlex
W2302566167
Cited by
396
References
2
Citations by year
2026: 26 · 2025: 51 · 2024: 52 · 2023: 38 · 2022: 52 · 2021: 48 · 2020: 40 · 2019: 38 · 2018: 19 · 2017: 24 · 2016: 7
FWCI
61.05
Type
journal article
Language
en
Update notices
correction (2016-07-21)
Open access
Licence
Locations
  • Dysphagia (publishedVersion, cc-by)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • ResearchOnline at James Cook University (James Cook University) (submittedVersion)
Topics
  • Health Sciences › Health Professions › Speech and Hearing › Dysphagia Assessment and Management
  • Health Sciences › Medicine › Physiology › Voice and Speech Disorders
  • Health Sciences › Medicine › Otorhinolaryngology › Head and Neck Cancer Studies
Keywords
oropharyngeal dysphagia, bolus viscosity, thickening agents, swallowing safety, penetration-aspiration, swallowing physiology, tongue pressure, hyoid displacement, palatability, dehydration, quality of life
MeSH terms
Biomechanical Phenomena, Deglutition, Deglutition Disorders, Europe, Food, Humans, Peristalsis, Pharynx, Reaction Time, Societies, Medical, Viscosity

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