When you or your loved one is first diagnosed with dysphagia, your doctor or specialist will typically recommend various tests to determine how severe the swallowing difficulties are, including the Dysphagia Severity Scale (DSS).
The Dysphagia Severity Scale is a standardized assessment tool used by healthcare professionals to measure and categorize swallowing difficulties into specific levels. This instrument has several versions from different researchers and experts. Some of the popular versions of the Dysphagia Severity Scale test are the DSS Scale by Waxman et al. (1990), FOIS, and PAS. What are they, and how can these instruments help someone with dysphagia have a safer life? Read more about DSS in this article.
Different Types of Dysphagia Severity Scale (DSS) Instruments
Healthcare providers usually use these Dysphagia Severity Scale instruments to check how severe someone’s dysphagia is. Each scale looks at different aspects of swallowing, and the results will help the healthcare providers figure out the best treatment plan and safety recommendations for. Let’s dive into some known instruments that have been used for years.
1. DSS Scale
The Dysphagia Severity Scale (DSS), created by Waxman et al. (1990), was a game-changer in helping standardize swallowing assessment. This thoughtful scale breaks things down into seven manageable levels, making it so much easier for healthcare teams to communicate and create effective treatment plans.
| Level | Description |
| Level 1 | Normal swallowing ability with no restrictions |
| Level 2 | Functional swallowing with minimal symptoms |
| Level 3 | Mild dysphagia requiring diet modifications |
| Level 4 | Moderate dysphagia with increased aspiration risk |
| Level 5 | Moderate-severe dysphagia requiring significant modifications |
| Level 6 | Severe dysphagia with minimal oral intake |
| Level 7 | Profound dysphagia requiring alternative nutrition |
2. FOIS
The Functional Oral Intake Scale (FOIS) focuses on what someone can eat and drink in real life, making it useful for tracking progress and setting realistic goals over time.
The key difference between DSS and FOIS is their approach to assessment. While DSS evaluates overall swallowing function and considers multiple factors like feeding independence and aspiration risk, FOIS specifically measures functional oral intake without getting into the technical details of how swallowing works.
| Level | Description |
| Level 1 | Nothing by mouth |
| Level 2 | Tube dependent with minimal attempts at food or liquid |
| Level 3 | Tube dependent with consistent oral food or liquid |
| Level 4 | Total oral diet of a single consistency |
| Level 5 | Total oral diet with multiple consistencies, but requiring special preparation |
| Level 6 | Total oral diet with multiple consistencies without special preparation, but with specific food limitations |
| Level 7 | Total oral diet with no restrictions |
3. PAS
The Penetration-Aspiration Scale (PAS) focuses specifically on airway safety during swallowing, providing detailed information that helps healthcare teams make informed decisions about eating safety.
What makes PAS different from both DSS and FOIS is its focus on one important thing: whether food or liquid goes down the wrong pipe into the airway and how the body reacts to it. While DSS looks at overall swallowing ability and FOIS measures what someone can eat and drink, PAS focuses specifically on breathing safety during swallowing. This makes PAS especially useful for checking if it’s safe for someone to eat and drink normally.
| Level | Description |
| Level 1 | Material does not enter the airway |
| Level 2 | Material enters the airway, remains above the vocal folds, ejected |
| Level 3 | Material enters the airway, remains above the vocal folds, not ejected |
| Level 4 | Material enters the airway, contacts the vocal folds, ejected |
| Level 5 | Material enters the airway, contacts the vocal folds, not ejected |
| Level 6 | Material enters the airway, passes below the vocal folds, ejected |
| Level 7 | Material enters the airway, passes below the vocal folds, not ejected despite effort |
| Level 8 | Material enters the airway, passes below the vocal folds, no effort to eject |
How to Access Your Dysphagia Severity Scale
Getting properly assessed for dysphagia involves working with healthcare professionals who use specific evaluation methods. While this assessment can’t be done at home, a professional evaluation provides valuable information for managing swallowing difficulties safely.
1. Clinical Assessment
This is typically where the assessment process begins, with healthcare providers gathering information about swallowing challenges and determining which tests would be most helpful.
a) History and Symptoms Severity
The healthcare team will want to understand the patient’s experience:
- When did the swallowing difficulty problems start?
- What makes the condition worse?
- How does the swallowing difficulty affect daily activities?
This conversation helps determine which assessment tools will provide the most useful dysphagia severity scale information for the situation.
b) Water Swallow Test
This straightforward test involves drinking measured amounts of water while the clinician observes for signs of swallowing difficulty. It provides initial insights into swallowing safety and helps determine if more detailed testing is needed.
c) Volume-Viscosity Swallow Test (V-VST)
This test involves trying different amounts and thicknesses of liquids, giving the healthcare team information about which consistencies work best for the patient. The results help create a plan based on the dysphagia severity scale assessment.
2. Instrumental Assessment
When more detailed information is needed, these specialized evaluations provide comprehensive insights into the swallowing process and help determine precise severity levels.
a) Videofluoroscopic Swallowing Study (VFSS)
Often considered the gold standard for dysphagia assessment, VFSS uses real-time X-ray imaging to observe the entire swallowing process. The patient consumes various textures mixed with a safe contrast material, and imaging captures the swallowing mechanics. This detailed evaluation helps identify specific problems and provides accurate dysphagia severity scale placement.
b) Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
FEES uses a thin, flexible camera inserted through the nose to provide direct visualization of throat structures during swallowing. This assessment method offers clear views of laryngeal function and can detect swallowing problems that other methods might miss. Combined with other assessment findings, FEES helps establish a comprehensive understanding of dysphagia severity.
What To Do After Knowing Your Dysphagia Severity Level
Once the dysphagia severity scale results are available, patients can work with their healthcare team to develop an effective management plan. Having this information provides a clear starting point for making appropriate adjustments to eating and drinking habits.
1. Take Things Slow and Make Gradual Changes
Learning where someone falls on the dysphagia severity scale provides helpful information for managing the condition. From here, you can shift your life gradually and shift your eating and drinking habits slowly to adjust to dysphagia conditions. You don’t need to do it alone; instead, you can seek support from a community or healthcare providers specialising in treating dysphagia.
A good starting point is learning about IDDSI food levels and liquid thickness classifications, which provide clear guidelines for texture modifications. Understanding these standardized levels helps ensure that food and drink modifications match the specific recommendations from the dysphagia severity scale assessment.
2. Keep Meals Interesting with Texture Changes and a Meal Plan
Finding out someone’s position on the dysphagia severity scale doesn’t mean giving up favorite foods; it’s about learning how to enjoy them safely. The key is creating weekly meal plans that match your required thickness levels with foods you actually like eating.
Start by listing favorite meals, then learn how to modify their textures while keeping the flavors. For example, chicken curry can be blended with extra sauce to maintain taste while meeting pureed consistency needs.
Once you’ve figured out these modifications, you can learn to create a periodical meal plan to avoid stressing out about what foods/drinks on the next meal. Aside from that, creating a structured weekly meal plan helps you stay organized and even prepare the foods/drinks as early as possible. Here’s an example of what a week might look like for someone requiring IDDSI level 4 food/drink consistency:
| Day | Breakfast | Lunch | Snack | Dinner |
| Monday | Pureed oatmeal with banana | Blended chicken and vegetable soup | Smooth yogurt | Pureed beef stew with mashed potatoes |
| Tuesday | Smooth scrambled eggs | Pureed tuna salad with crackers (soaked) | Pudding | Blended pasta with meat sauce |
| Wednesday | Pureed fruit smoothie | Creamy tomato soup with soft bread | Applesauce | Pureed fish with mashed vegetables |
| Thursday | Soft pancakes with syrup | Blended lentil soup | Smooth ice cream | Pureed chicken curry with rice |
| Friday | Pureed breakfast bowl | Creamy mushroom soup | Jello | Blended meatloaf with gravy |
| Saturday | Smooth porridge | Pureed sandwich filling | Milkshake | Blended stir-fry with sauce |
| Sunday | Pureed French toast | Creamy potato soup | Custard | Pureed roast dinner |
3. Learn to Do the Flow Test at Home
Learning how to do IDDSI flow tests at home helps you check liquid thickness independently, which is useful as you work with different levels of the dysphagia severity scale. You just need a 10ml syringe, a timer or stopwatch, and a flat surface to perform these tests.
We already created a full guide on how to do an IDDSI flow test at home using these tools. You can check it here.
When you’re dealing with dysphagia, it’s all about getting to know what works for your swallowing and making sure your meals are both safe and enjoyable. Understanding where you fall on the dysphagia severity scale can be super helpful in figuring out which foods and drinks are right for you. Stay tuned with DysphagiaLiving.com for more useful tips and guides on how to live your best life with dysphagia.
References
- Waxman, M. J., Durfee, D., Moore, M., & Morantz, R. A. (1990). Nutritional aspects and swallowing function of patients with Parkinson’s disease. Nutrition in Clinical Practice, 5(5), 196-201. Available at: https://doi.org/10.1177/011542659000500502
- Cichero, J. A., Lam, P., Steele, C. M., Hanson, B., Chen, J., Dantas, R. O., … & Stanschus, S. (2017). Development of international terminology and definitions for texture-modified foods and thickened liquids used in dysphagia management: The IDDSI framework. Dysphagia, 32(2), 293-314. Available at: https://doi.org/10.1007/s00455-016-9758-y
- Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11(2), 93-98. Available at: https://doi.org/10.1007/bf00417897
