Dysphagia & the IDDSI framework
Dysphagia means difficulty swallowing. Because a texture that's safe for one person can be unsafe for another, the IDDSI framework gives every food and drink a shared number — so the level your clinician prescribes is the level you can look for in a recipe.
The eight IDDSI levels
Levels 0–4 describe drinks by how thick they are; levels 3–7 describe foods by how much chewing they need. Levels 3 and 4 sit in both — they can be sipped or spooned.
Testing a texture at home
You don't need lab equipment — IDDSI's own tests use a fork, a spoon, and a syringe.
- Fork drip test. Watch how it comes off the tines: flowing freely is thin; dripping slowly in dollops is moderately thick; sitting in a mound is puréed.
- Spoon tilt test. A Level 4 purée should slide off a tilted spoon in a single blob, holding its shape — not pour off, and not stick fast.
- Fork pressure test. Press with the fork until your thumbnail blanches. Level 6 food should break apart; Level 5 should squash easily and stay moist.
- Particle size. The gaps between fork tines are about 4 mm — a useful gauge for Level 5. Level 6 pieces should be no wider than about 15 mm.
Thickening drinks well
- Add thickener gradually and stir thoroughly — then let it stand. Most thickeners keep thickening for several minutes, so test after it settles, not immediately.
- Re-check before serving; a drink left sitting can drift to a thicker level than prescribed.
- Thickening changes taste and mouthfeel. Naturally thick drinks — smoothies, lassi, kefir, nectar — are often more pleasant than thickened water.
- Too thick is not safer. Over-thickened drinks are tiring, leave residue, and are a common cause of dehydration.
Safer swallowing at mealtimes
- Sit fully upright, and stay upright for 20–30 minutes after eating.
- Eat slowly with small spoonfuls; finish and clear each mouthful before taking the next.
- Minimise distraction — no talking mid-mouthful, and keep the TV off if concentration is hard.
- Rest when you tire. Fatigue late in a meal is when most difficulty happens, so eat smaller amounts more often.
- Keep the mouth clean before and after eating; good oral hygiene meaningfully lowers the risk of aspiration pneumonia.
- Take medications the way your team advised — crushing tablets or opening capsules is not always safe.
Swallowing exercises
Exercises a speech-language pathologist may prescribe as part of dysphagia therapy, filterable by what each one targets. This is a reference so you can look up a prescribed exercise — not a menu to choose from yourself. Your clinician sets which exercises, how many repetitions, how long to hold, and how long to rest.
Effortful swallowStrengthens the swallow itself
HowCollect all the saliva in your mouth onto the centre of your tongue. Keep your lips closed and tight together. Pretend you are swallowing a grape whole, in one big, hard swallow.
Lollipop swallowingSwallow strength with a taste cue
HowPlace a sugarless lollipop in your mouth and lick it three times, then do an effortful swallow with your lips firmly pressed together. Swallow as hard as you can.
Masako manoeuvreBack-of-throat wall strength
HowStick your tongue out between your front teeth and gently bite down to hold it in place. Swallow while keeping the tongue gently between your teeth. You can let go between swallows and repeat.
CautionTongue is held gently — never bite hard.
Mendelsohn manoeuvreProlongs the swallow’s open phase
HowPlace your middle three fingers on your Adam’s apple. Swallow once to practise, feeling it slide upward. Swallow again and, at its highest point, squeeze your throat muscles to hold it up there for as long as your clinician directed.
Supraglottic manoeuvreProtects the airway during the swallow
HowCollect a small amount of saliva. Take a deep breath and hold it, keep holding while you swallow, then cough immediately afterwards. Practise with saliva before food or liquid.
CautionOnly if specifically directed by your clinician, who should also tell you the head position to use (tucked, right, left, or straight).
Isokinetic (dynamic) ShakerStrengthens the muscles that open the upper oesophagus
HowLie flat with no pillow. Keep your shoulders flat and lift your chin toward your chest so you can see your toes, then immediately lower your head. Repeat for the prescribed reps, rest, and repeat the prescribed sets.
CautionShoulders stay flat on the surface throughout.
Isometric (static) ShakerSustained hold version of the Shaker
HowLie flat with no pillow. Keep shoulders flat and lift your chin toward your chest so you can see your toes. Hold for as long as prescribed, set your head down, and rest. Repeat as prescribed.
CautionShoulders stay flat on the surface throughout.
YawnStretches the throat and jaw
HowYawn, and when you reach a big stretch hold that position for as long as indicated.
Tongue strength exerciseStrengthens front, middle and back of the tongue
HowUsing a tongue depressor, press the tip of your tongue out against it, then place it on the tip and push up. For the middle, place the depressor mid-tongue and push up against the roof of your mouth. For the back, say the “k” sound, place the depressor where the tongue touched the roof, and push up. Then sweep the tip from front to back along the roof of your mouth, and finally move your tongue from one corner of your mouth to the other.
Tongue range of motionRestores full tongue movement
HowStick your tongue out as far as possible and hold as instructed. Pull it back into your mouth as far as you can. Move the tip to one corner of your mouth and hold, then the other side. Finally, open your mouth, put the tip behind your top teeth, and hold the stretch.
Tongue retractionStrengthens the back of the tongue
HowDon’t use the tip of your tongue. Instead, pull the back of your tongue as far into your mouth as you can, and hold.
Jaw thrustJaw and throat opening
HowMove your lower jaw as far forward as you can, so your lower teeth sit in front of your upper teeth.
CautionPatients with a jaw replacement should use extra caution before performing this exercise, so as not to stress the jaw bone.
Effortful pitch glideWorks the voice box and throat closure
HowSay “eee” at as low a pitch as possible, then gradually raise the pitch of your voice to the highest tone you can. Hold that tone for the length of time your clinician directed.
Lip range of motionLip seal and facial mobility
HowPull your lips into a smile and hold the stretch. Next, open your jaw wide, then stretch your lips into a smile and hold.
Head & neck cancer and dysphagia
Swallowing difficulty can appear at any stage of head and neck cancer treatment — from the tumour itself, from surgery, or from radiation-induced scarring that shows up long afterwards. What helps differs by stage, so the guidance below is grouped that way.
Stage 1Before treatment startsPreparation makes the rest of the process markedly easier
Build your care team early
- Speech-language pathologist — discuss what to expect of your swallow, and learn exercises and strategies before you need them.
- Dietitian — set up a plan for maintaining nutrition and hydration through treatment.
- Dentist — find out whether pre-treatment dental work, such as extractions, is needed.
Start swallowing exercises early
Learning oral and pharyngeal exercises before treatment begins removes the burden of learning them while you are unwell. The exercise library above is a reference for what your SLP may prescribe.
Stage 2During treatmentProtect the swallow while side effects are at their peak
Oral care is critical
Brush with a soft toothbrush two to three times daily with fluoridated toothpaste, floss twice daily, and use a topical fluoride rinse or gel. A clean mouth means fewer sores and less bacteria.
Diet and hydration
- Avoid carbonated, sugary, and acidic drinks.
- Sip water regularly to keep tissues hydrated and the muscles engaged.
- Swallow small amounts of food or liquid every day to maintain swallowing function.
Keep exercising, and keep in touch
Swallowing exercises performed during treatment are associated with fewer difficulties later, so ask your SLP for a personalised plan and see them regularly as symptoms change.
Stage 3After treatmentLate radiation-associated dysphagia can appear months or years later
Difficulty can persist or emerge long after treatment ends — commonly as dry mouth, reduced mouth opening, tissue stiffness, or narrowing of the throat. None of these are things to simply live with: each has a specific treatment, listed in the reference below.
Worth asking about
Newer radiation techniques such as IMRT target cancerous tissue while sparing nearby healthy areas. If your treatment involves the vocal cords, ask your radiation oncologist how your voice can be protected.
Symptom reference — and what helps
MucositisPainful inflammation and mouth sores
What helpsBrush with a soft toothbrush two to three times daily using fluoridated toothpaste, floss twice daily, and use a topical fluoride rinse or gel. Keeping the mouth clean minimises bacteria and reduces sores.
Xerostomia (dry mouth)Reduced saliva makes swallowing harder
What helpsSip water regularly to keep the tissues hydrated and the muscles engaged. Avoid carbonated, sugary, and acidic drinks. Over-the-counter dry-mouth rinses and toothpastes are made for this.
Altered taste and sensationFood becomes unappealing
What helpsExpect interest in eating to drop, and plan around it — swallow small amounts of food or liquid every day to keep the swallow working even when appetite is low.
Nausea or painAppetite and intake fall
What helpsTell your team early; managing nausea and pain is what makes eating possible. A dietitian can adjust the plan so intake holds up while symptoms are treated.
DermatitisSkin inflammation in the treated area
What helpsA treatment-related side effect your oncology team manages. Raise it at review rather than treating it yourself.
TrismusReduced ability to open the mouth
What helpsPerform the exercises and stretches your SLP recommends to maintain or regain mobility. The jaw exercise library covers the opening and stretching work in detail.
FibrosisTissue stiffness from radiation scarring
What helpsOngoing SLP-directed exercise is the mainstay. Consistency over months matters more than intensity in any one session.
StricturesNarrowing of the throat or oesophagus
What helpsAn ENT or GI doctor may perform a procedure to stretch the narrowed area. Food feeling stuck is the symptom to report.
HoarsenessVoice changes after treatment
What helpsAn SLP or ENT can evaluate your vocal cords and offer treatment to improve the voice.
Weight loss and poor intakeNutrition falls behind healing needs
What helpsA dietitian can tailor a plan that meets your needs despite swallowing difficulty. Track it with the weight tracker — more than about 5% below your starting weight is a signal to contact your team.
Support and further reading
The National Foundation of Swallowing Disorders (NFOSD) is the leading patient-facing dysphagia organisation, and much of the guidance on this page reflects theirs. Their own resources go further than we can here:
- Swallowing and head & neck cancerNFOSD's full guide to dysphagia before, during, and after cancer treatment.
- Swallow exercises, with video for eachNFOSD hosts a demonstration video for every exercise in the library above.
- Finding the right swallowing specialistHow to find and choose an SLP experienced in dysphagia.
- Peer-to-peer mentoringSpeak with someone who has been through the same recovery.
- Virtual swallowing support groupMeets online; there is also a separate caregiver support group.
- Understanding your assessmentWhat happens during a swallow study, and what the results mean.
- Patient storiesFirst-hand accounts from people living with dysphagia.
Who sets your level
A speech-language pathologist assesses your swallow and prescribes the IDDSI level; a dietitian makes sure that level still delivers enough protein, energy, and fluid. Both should review you periodically — dysphagia can improve or worsen, and the diet should follow. Long-term maintenance at a stable level is a normal, expected outcome for many people, particularly after reconstruction or resection.
Find recipes at your level
Filter the library straight to the IDDSI level you've been prescribed, with protein and calories listed for every recipe.
Browse recipes by IDDSI level →