Written by Leon and Athanasia Daley, co-owners of Daley Dysphagia Diagnostics, LLC.

Dysphagia, or a swallowing disorder, can lead to serious affects that could impact someone’s
nutrition status, overall well-being, and quality of life. As medical professionals, it is important
that we stay up to date with what the evidence suggests to provide the most effective care
possible. There are many myths floating around and Speech-Language Pathologists have to
educate patients, families, and other medical staff to combat the spread of misinformation.
Through proper education and collaboration, we can all work to improve patient outcomes,
reduce risk of hospitalization, and promote quality of life in our patients living with dysphagia.
Here are some myths that we busted!

Myth #1:
The Thicker the Liquid, the Better the Swallow!

    • Thickener always prevents aspiration. If someone coughs with thin liquid, give them
      nectar (mildly thick) or honey (moderately thick) thickened liquids.
  • FACT:
    • Thickened liquids do not prevent aspiration in all people with dysphagia (Kaneoka et al,
      2017; Vilardell et al, 2016).
    • Studies have shown that up to 40% of individuals aspirate nectar thickened liquids
      (Vilardell et al, 2016).
    • Pulmonary injury is worse in individuals aspirating cornstarch-based thickeners. Xanthan
      gum-based thickeners, though better than cornstarch-based thickeners, are worse for the
      lungs than thin water (Nativ-Zeltzer et al., 2018).
    • Thickened liquids have been associated with dehydration, which can also lead to negative
      health outcomes such as UTI, electrolyte imbalance, constipation, fecal impaction,
      cognitive impairment, failure to thrive, and even death (Langmore, 2002; Panther, 2016).
    • In 2008, 150,000 elderly adults were admitted to the hospital for dehydration, costing
      more than $2 billion (Panther, 2016).
    • No significant difference was noted regarding the appreciation of aspiration pneumonia
      between individuals on thin and thickened liquids in low-risk patients (Kaneoka et al,
      2017; Panther, 2016).

Myth #2:
A Chin Tuck Fixes Everything

    • If any person has trouble swallowing, using a chin down or chin tuck maneuver will
      improve the swallow and mitigate aspiration.
  • FACT:
    • While the chin tuck maneuver can be helpful for some individuals, it can decrease
      swallow safety or have no benefit at all in others (Logemann, 1993; Sheffler, n.d.).
    • Only a FEES or MBSS can tell us if a chin tuck is effective by assisting in redirecting the
      bolus away from the airway, thus improving swallow safety.
    • Terre & Mearin (2012) found the chin tuck maneuver to be effective in only 55% of
      individuals with dysphagia.

Myth #3:

PEG Tubes = NPO

    • Patients only have PEG tubes if there is a severe dysphagia present. In which case, these
      patients should be kept strictly NPO because there is little to no chance of the patient
      being able to tolerate a PO diet.
  • FACT:
    • Although PEG tubes are frequently placed due to severe dysphagia, the presence of a
      PEG tube does not necessarily mean that the patient is not safe to accept solids/liquids by
    • PEG tubes are often placed due to significantly reduced oral intake or an inability to
      achieve adequate nutrition/hydration by mouth.
    • Most often this is secondary to head/neck cancer or acute illness/injury resulting
      in decreased alertness or ability to eat (Shaw et al., 2015)
    • Frequently, patients significantly improve functioning in post-acute care settings,
      meaning they can participate in therapeutic exercises for dysphagia (which often involves
      trials of PO intake) and work towards weaning from the PEG (Mittal et al, 2015).

Myth #4:
Break The Silence!

    • If a patient does not cough while eating/drinking, they don’t have dysphagia.
  • FACT:
    • Silent aspiration (aspiration with no overt cough or other sensory response) occurs in as
      many as 25-52% of patients in the acute care setting (Leder et al, 2011).
    • Although a cough or throat clear doesn’t necessarily mean dysphagia or that
      someone is aspirating either!
    • Oral dysphagia may not result in aspiration but can have a profound negative effect on an
      individual’s health status.
    • Decreased mastication may lead to decreased appetite and reduced food intake
      (Hollis, 2018).
    • Presence of oral dysphagia doubles the likelihood of depression in elderly adults
      (Shin et al., 2016).

Myth #5:
Sponge Swabs are Effective and Adequate for Oral Care

    • Using a sponge swab dipped in mouthwash is adequate for oral care.
  • FACT:
    • Sponge swabs are not successful in removing built-up plaques and biofilm that manifest
      pathogenic microorganisms (which contributes to the development of aspiration
      pneumonia) (Sheffler, 2018).
    • Nothing is more effective at decreasing the development of gram-negative bacteria than
      thorough cleaning with a toothbrush and toothpaste! (Sheffler, 2018)
    • For tube fed patients, Maeda & Akagi (2014) found that pneumonia was twice as likely in
      the group that had no oral care protocol as compared to those getting oral care. They
      additionally found that standard oral care given twice daily resulted in a 40% decrease in

Myth #6:

Aspiration Always Leads to Pneumonia

    • If a patient is seen to aspirate on an instrumental assessment, they will get pneumonia
      unless they are recommended thickened liquids, altered diet consistencies, or NPO.
  • FACT:
    • We know there are 3 main factors that contribute to the development of aspiration
      pneumonia (Ashford, n.d.):
      • Compromised Immune System
      • The Presence of Aspiration
      • Poor Oral Health
    • Susan Langmore (2002) listed the predictors of aspiration pneumonia to be:
      • Suctioning
      • Chronic Obstructive Pulmonary Disorder (COPD)
      • Congestive Heart Failure (CHF)
      • Presence of Feeding Tube
      • Bedridden
      • High Case Mix Index
      • Delirium
      • Weight Loss
      • Dysphagia
      • Urinary Tract Infection (UTI)
    • Research shows that 18% of healthy young adults silently aspirate regularly without
      pulmonary complications reported (Butler et al, 2018).
    • Only 12% of individuals who aspirate actually develop an aspiration-related pneumonia
      (Robbins et al., 2008).

Myth #7:
PEG Tubes Improve Outcomes

    • PEG tubes are the end-all-be-all for prevention of aspiration and pneumonia, improving
      outcomes and reducing deleterious effects from dysphagia.
  • FACT:
    • Patients with PEG tubes are often kept NPO, which prevents rehabilitation of the swallow
      mechanism with the use of bolus-drive exercise programs (Mittal et al, 2015).
    • Individuals with PEG tubes are likely to encounter negative outcomes such as aspiration
      of reflux which can lead to aspiration pneumonitis, pneumonia, malnutrition, site
      infections, or GI bleeds, (Komiya et al, 2018).
    • There is no current supportive evidence justifying the use of PEG tube feeding in
      improving outcomes for individuals with dementia or dysphagia (Komiya et al, 2018).
      In Conclusion:
    • Aspiration pneumonia doesn’t occur in isolation. There are multiple factors that
      contribute to the development of aspiration pneumonia (Ashford, n.d.).
    • Modifying diets or using compensatory strategies without instrumentals can lead to poor
      outcomes or even death (Langmore, 2002; Panther, 2016).
    • Swallow compensation techniques need to be tested during an instrumental test to
      determine whether they are effective (Logemann, 1993; Sheffler, 2015; Terre & Mearin,
    • PEG tubes don’t necessarily lead to improved outcomes (Komiya et al, 2018).
    • Nothing beats a toothbrush! (Sheffler, 2018)


  • Ashford, J. R. (n.d.). Three Pillars of Pneumonia. Retrieved from
  • Butler, S. G., Stuart, A., Markley, L., Feng, X., & Kritchevsky, S. B. (2018). Aspiration
    as a Function of Age, Sex, Liquid Type, Bolus Volume, and Bolus Delivery Across the
    Healthy Adult Life Span. Annals of Otology, Rhinology, & Laryngology, 127(1), 21–32.
  • Hollis, J. H. (2018). The effect of mastication on food intake, satiety, and body weight.
    Physiology & Behavior, 193(April), 242–245.
  • Kaneoka, A., Pisegna, J. M., Saito, H., Lo, M., Felling, K., Haga, N., … Langmore, S. E.
    (2017). A systematic review and meta-analysis of pneumonia associated with thin liquid
    vs . thickened liquid intake in patients who aspirate. Clinical Rehabilitation, 31(8),
  • Komiya, K., Usagawa, Y., & Kadota, J. (2018). Decreasing Use of Percutaneous
    Endoscopic Gastrostomy Tube Feeding in Japan. Journal of the American Geriatrics
    Society, 66(7), 1388–1391. https://doi.org/10.1111/jgs.15386
  • Langmore, S. E., Skarupski, K., Park, P., & Fries, B. (2002). Predictors of Aspiration
    Pneumonia in Nursing Home Residents. Dysphagia, 17(4), 298–307.
  • Leder, S. B., Suiter, D. M., & Green, B. G. (2011). Silent Aspiration Risk is Volume-
    dependent. Dysphagia, 26, 304–309.
  • Logemann, JA (1993). Manual for the Videoflourographic Study of Swallowing: Second
    Edition. Austin, TX: Pro-Ed
  • Maeda, K., Akagi, J. Oral care may reduce pneumonia in the tube-fed elderly: a
    preliminary study. Dysphagia. 2014;29:616–621.
  • Mittal, R., Mishra, A., & Nilakantan, A. (2015). Therapeutic interventions by speech
    language pathologist in managing adult dysphagia: An evidence based review. Journal of
    Laryngology and Voice, 5(1), 11.
  • Shaw, S. M., Flowers, H., Sullivan, B. O., Hope, A., Liu, L. W. C., & Martino, R. (2015).
    The Effect of Prophylactic Percutaneous Endoscopic Gastrostomy ( PEG ) Tube
    Placement on Swallowing and Swallow-Related Outcomes in Patients Undergoing
    Radiotherapy for Head and Neck Cancer : A Systematic Review. Dysphagia, 30,
  • Sheffler,K. The Toothbrush Defense. The ASHA Leader, May 2018.
  • Sheffler, K. (2015). To chin tuck, or not to chin tuck? That is the question. Retrieved
    November 24, 2018 from https://www.swallowstudy.com/to-chin-tuck-or-not-to-chin-
  • Shin, H., Ahn, Y., & Lim, D. (2016). Association Between Chewing Difficulty and
    Symptoms of. Dental and Oral Health, 64(12), 270–278.
  • Terre, R. & Mearin F. (2012). Effectiveness of chin-down posture to prevent tracheal
    aspiration in dysphagia secondary to acquired brain injury: A videofluoroscopy
    study. Neurogastroenterology & Motility, 24, 414-e206.
  • Panther, K. (2016). Best practices for dehydration prevention. Perspectives of the ASHA
    Special Interest Groups – SIG 13, 1(2), 72-80.
  • Robbins, J., Gensler, G., Hind, J., Logemann, J., Lindblad, A., Brandt, D., … Miller
    Gardner, P. (2008). Comparison of 2 Interventions for Liquid Aspiration on Pneumonia
    Incidence: A Randomized Trial. Annals of Internal Medicine, 148, 509–518.
  • Vilardell, N., Rofes, L., Arreola, V., Speyer, R., & Clave, P. (2016). A Comparative Study
    Between Modified Starch and Xanthan Gum Thickeners in Post-Stroke Oropharyngeal
    Dysphagia, 169–179.

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