584381

research-article2015
CRE0010.1177/0269215515584381Clinical RehabilitationMortensen et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

A validation study of the Facial- 1­–6

© The Author(s) 2015
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DOI: 10.1177/0269215515584381

Assessment of Saliva cre.sagepub.com

Jesper Mortensen1,2, Ditte Jensen1 and

Annette Kjaersgaard1

Abstract
Objective: To investigate the validity and reliability of the Swallowing Assessment of Saliva in detection
of aspiration risk.
Design: Validation study.
Setting: Inpatient neurorehabilitation centre.
Subjects: Adult patients with acquired brain injury. A total of 43 patients for concurrent validity and 33
other patients for inter-rater reliability.
Interventions: Concurrent validity was established with blinded Swallowing Assessment of Saliva and
endoscopic evaluation within a 24-hour time interval. Inter-rater reliability was established with two
blinded Swallowing Assessments of Saliva within a one-hour time interval.
Main measures: The Swallowing Assessment of Saliva is a seven-item scale with a combination of
swallowing and non-swallowing items. It is based on the Facial-Oral Tract Therapy approach.
Results: The Swallowing Assessment of Saliva had a sensitivity of 91%, 95% confidence interval (CI)
(59; 100), a specificity of 88% %, 95% CI (71; 97) and a kappa coefficient of 0.87 ±0.17 in detection of
aspiration risk. Furthermore, analyses showed that experienced and inexperienced occupational therapists
performed equally in detection of aspiration risk.
Conclusion: The Swallowing Assessment of Saliva is a simple, sensitive and reliable assessment for
detecting aspiration risk in patients with acquired brain injury.

Keywords
Dysphagia, brain injury, assessment, validity, Facial-Oral Tract Therapy

Received: 28 October 2014; accepted: 4 April 2015

1Hammel Neurorehabilitation Centre and University Research Corresponding author:

Clinic, Hammel, Denmark Jesper Mortensen, Department of Public Health, University of
2Department of Public Health, University of Copenhagen, Copenhagen, Gothersgade 160, 1123 Copenhagen, Denmark.
Copenhagen, Denmark Email: Jemo@sund.ku.dk

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2 Clinical Rehabilitation 
Introduction
A common complication following acquired brain
injury is oropharyngeal dysphagia, which is often
associated with a risk of aspirating food, liquids or
saliva.1 Aspiration may lead to pneumonia, which
can cause complications that might prolong hospi-
talization and increase mortality risk.1 Thus, proper
assessment of aspiration risk is vital in minimizing
the risk of pneumonia.2 Facial-Oral Tract Therapy
is an approach that provides both clinical assess-
ment and treatment of oropharyngeal dysphagia.2,3
In the Facial-Oral Tract Therapy approach, a pre-
requisite for the initiation of oral intake is safe
swallowing of saliva.3
A recent randomized controlled trial showed
that patients assessed for initiation of oral intake
with an Facial-Oral Tract Therapy-based clinical
assessment, hereinafter referred to as the
Swallowing Assessment of Saliva, were not more
likely to develop aspiration pneumonia than
patients who were assessed with an endoscopic
evaluation.2 However, the randomized study did
not investigated whether therapists reach the same
conclusion following Swallowing Assessment of
Saliva compared with the endoscopic evaluation,
which is essential if the clinical assessment is to
obviate endoscopic evaluations. Furthermore, it is
important to establish whether therapists reach the
same conclusion from clinical assessments.
Based on this, the objective of the present study
was to investigate the concurrent validity and inter-
rater reliability of Swallowing Assessment of
Saliva in detection of aspiration risk, in patients
with acquired brain injury at a subacute inpatient
neurorehabilitation centre.
Method
Data for concurrent validity (Study 1) was gathered
as part of the aforementioned randomized con-
trolled trial.2 Data for inter-rater reliability (Study
2) was collected in an additional study, and no ethi-
cal approval was needed because the Swallowing
Assessment of Saliva is part of standard clinical
practice for occupational therapists at the present
centre. Informed or surrogate consent was obtained
for all enrolled patients. Inclusion criteria were:
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acquired brain injury, ⩾18 years of age, assess-
ments made within 48 hours of admission, and
Functional Oral Intake Scale score <7 at admis-
sion.2 Exclusion criteria were: tracheostomy tube
and pneumonia at admission.2
Swallowing Assessment of Saliva
The Swallowing Assessment of Saliva consists of a
visual assessment of the oral structure and a tactile
assessment with swallowing of saliva (Appendix).
Based on the assessment it is concluded whether
oral intake should be initiated. Patients may be in a
sitting or reclined position (owing to reduced head
control) during assessment. At the present rehabili-
tation centre, assessments of dysphagia are per-
formed by occupational therapists. The Swallowing
Assessment of Saliva is part of a large assessment
battery that is described elsewhere.3
Study 1: Concurrent validity
Concurrent validity was investigated by having
patients assessed with both Swallowing Assessment
of Saliva and endoscopic evaluation within a
24-hour interval. Endoscopic evaluations were car-
ried out by an interdisciplinary team consisting of a
physician and an occupational therapist, with no
knowledge of the results from the preceding
Swallowing Assessment of Saliva. Additional
methodological details on endoscopic evaluations
and the clinical setting are described in the article
by Kjaersgaard et al.2 We used sensitivity, specific-
ity and predictive values to establish the concurrent
validity. A total of 43 patients admitted between
August 2009 and April 2011 were included.
Subanalyses were carried out to investigate whether
experienced and inexperienced occupational thera-
pists performed equally in the detection of aspira-
tion risk. Experienced occupational therapists were
defined as those who had completed a basic Facial-
Oral Tract Therapy course3 and had ⩾2 years of
clinical experience.
Study 2: Inter-rater reliability
Inter-rater reliability was established by having
patients assessed with Swallowing Assessment of
Mortensen et al. 3

Table 1.  General characteristics of patients for investigating validity and reliability of the Swallowing Assessment of
Saliva.

Study 1: Concurrent validity (n = 43) Study 2: Inter-rater reliability (n = 33)

Age 59 (50–68) 58 (49–65)
Sex, male 31 (72%) 20 (61%)
Diagnosis
 - Stroke 31 23
 - TBI 5 4
 - Other diagnosis 7 6
Days in acute care 30 (24–54) 35 (17–70)
FOIS 2 (1–3) 2 (1–5)
FIM 23 (18–38) 26 (20–42)
RLAS 5 (4–6) 5 (5–6)
PAS 4 (1–7) —

Data presented as median (IQR). FOIS, FIM, RLAS, and PAS were registered at admission at the inpatient neurorehabilitation
centre. Other diagnoses consist of anoxia cerebri, polyneuropati, encephalitis and brain tumours.
FOIS: Functional Oral Intake Scale; FIM: Functional Independence Measure; RLAS: Rancho Los Amigos Scale; PAS: Penetration
Aspiration Scale.

Table 2.  Study 1: Concurrent validity of the Swallowing Assessment of Saliva with endoscopic evaluation as
reference.

Stratified analysis Overall precision

  Experienced occupational Inexperienced occupational  

therapists (n=15) therapists (n=12)
Patientsa 28 14 43
True/false positive 5/3 5/1 10/4
True/false negative 19/1 8/0 28/1
Prevalence of aspiration 6 (21%) 5 (36%) 11 (26%)
Sensitivity 83% (36; 100) 100% (48; 100) 91% (59; 100)
Specificity 86% (65; 97) 89% (52; 100) 88% (71; 97)
Positive predictive value 63% (25; 92) 83% (36; 100) 71% (42; 92)
Negative predictive value 95% (75; 100) 100% (63; 100) 97% (82; 100)

Sensitivity, specificity and predictive values are reported as mean, 95% CIs. Positive = Aspiration risk.
aIt was only possible to establish the experience level of occupational therapists for 42/43 clinical assessments.

Saliva by two occupational therapists within a time
limit of one hour between assessments. The second
assessment was carried out blind to results from the
first assessment. We used kappa-coefficients to
establish the inter-rater reliability. A total of 33
patients admitted between October 2013 and
March 2014 were included.
Results
Baseline characteristics for patients are presented
in Table 1. All patients in Study 1 had either a
percutaneous endoscopic gastrostomy or nasal tube
at admission. In Study 2, 10 patients had a percu-
tanous endoscopic gastronomy tube, 16 patients
had a nasal tube and seven patients had no feeding
tube at admission.
The results for Study 1 are presented in Table 2.
A total of 27 occupational therapists carried out
one or more of the 43 assessments.
The results for Study 2 are presented in Table 3.
The prevalence of aspiration risk in the 33 patients
was 33%. This calculated prevalence was based on
conclusions from the second Swallowing Assessment

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4 Clinical Rehabilitation 

Table 3.  Study 2: Inter-rater reliability of the Swallowing Assessment of Saliva.

Swallowing Assessment of Saliva Agreement Kappa SE p-value

1. Conscious and/or response to verbal addressa 94% — — —
2. Able to sit upright with some head control 97% 0.87 ±0.17 p < 0.001
3. Oral transport of saliva 88% 0.53 ±0.17 p < 0.001
4. Spontaneous or facilitated swallowing of saliva 91% 0.68 ±0.16 p < 0.001
5. Coughing following swallowing of saliva 94% 0.63 ±0.17 p < 0.001
6. Gurgling breath sound following swallowing of saliva 79% 0.30 ±0.12 p < 0.01
7. Difficulties breathing following swallowing of saliva 88% 0.43 ±0.17 p < 0.01
Overall agreement 94% 0.87 ±0.17 p < 0.001

Inter-rater reliability was established in 33 patients with acquired brain injury.

aIt was not possible to establish the kappa value because of a low prevalence of patients not being conscious and/or responding to

verbal address.

of Saliva. All patients were in the same position at
both assessments. A total of 18 patients were in an
upright position during assessments and 15 patients
were in a reclined position. A total of 13 occupational
therapists were involved in assessment of one or
more patients.
Discussion
In the present study we have shown that the
Swallowing Assessment of Saliva is a sensitive and
reliable tool for detection of aspiration risk. In addi-
tion, experienced and inexperienced occupational
therapists performed equally well in detection of
aspiration risk. However, results show that items
regarding oral transport of saliva, difficulties in
breathing and gurgling breath sounds may be diffi-
cult to assess. Thus, to facilitate uniform assess-
ment, specific training in evaluating these items
may be necessary.
It could be argued that item 1, regarding con-
sciousness, should not be included as it evaluates
prerequisites for assessment, rather than contribut-
ing with information regarding the swallowing
function.4 However, if a patient is not conscious
enough to perform safe swallowing, then it is
essential to report this issues, as it will facilitate the
development of the treatment plan.4
As recommended,5 it is necessary to have a
combination of swallowing and non-swallowing
items in the detection of aspiration risk. Swallowing
Assessment of Saliva has many similarities
with other validated screening tools and clinical
assessments, such as the Standardized Swallowing
Assessment6 and the Mann Assessment of
Swallowing Ability7 with regards to swallowing
items such as control of saliva, and non-swallow-
ing items such as consciousness.6,7
The Standardized Swallowing Assessment has a
sensitivity of 47%–68%, a specificity of 67%–86%
and a kappa coefficient of 0.50–0.79 in detection of
aspiration risk, when administered by speech lan-
guage therapists or doctors;8 and the Mann
Assessment of Swallowing Ability has a sensitivity
of 93%, a specificity of 63% and a kappa coeffi-
cient of 0.41 in detection of aspiration risk, when
administered by speech language therapists.7
Based on the present results, the Swallowing
Assessment of Saliva may be a more valid and relia-
ble tool than the abovementioned assessments, with
a sensitivity of 91%, a specificity of 88% and a kappa
coefficient of 0.87. However, wide confidence inter-
vals partly influenced by the small study sample
weaken conclusions. Also, kappa coefficients depend
on the prevalence of the diagnosis, which should be
taken into account when comparing results.9
Another screening tool that has been highlighted
in a systematic review10 is the Toronto Bedside
Swallowing Screening Test.11 However, this assess-
ment has been validated with dysphagia as the out-
come, whereas we investigated validity and
reliability with aspiration risk as the outcome,
which is embedded in the definition of dysphagia,
but does not define dysphagia exclusively.4
The Swallowing Assessment of Saliva may be a
safer assessment compared with the abovementioned

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Mortensen et al. 5
assessments, since it does not include sipping/drink-
ing water, but only swallowing of saliva. Thus, risk
of aspiration during assessment is minimized. In
addition, the Swallowing Assessment of Saliva does
not include items regarding voice quality, and may
therefore be more appropriate for assessment of
severely brain-injured patients with aphasia.
It has been stated that screening for dysphagia
may refer to actual testing at a patient’s bedside.10
The Swallowing Assessment of Saliva can be com-
pleted in a relatively short time and provides a yes/
no conclusion, which are relevant features for a
screening tool.4 However, a diagnosis is given
based on the assessment, which differentiates it
from a screening, in which the aim is to identify
patients who require further diagnostic evaluation.4
Furthermore, the Swallowing Assessment of Saliva
contributes with recommendations for the prelimi-
nary treatment plan, which also differentiates it
from a screening.4,10
A limitation of this study is that patients with tra-
cheostomy tube and pneumonia at admission were
excluded, which weakens generalizability of results.
These criteria were chosen for the preceding rand-
omized study as both criteria could influence the
primary outcome of that study (pneumonia during
rehabilitation). Because we included patients from
the randomized study in our Study 1, we had no
influence on these criteria. To increase the homoge-
neity of study populations, we therefore decided to
use these exclusion criteria in Study 2 as well.
This study contributes to findings from a preced-
ing randomized study, showing that the Swallowing
Assessment of Saliva may potentially obviate the
use of endoscopic evaluations for detection of aspi-
ration risk, and thus minimize time and resources
on assessments. Furthermore, the Facial-Oral Tract
Therapy approach, which constitute the theoretical
frame underlying the Swallowing Assessment of
Saliva, is used in many countries,3 which strength-
ens the applicability of the Swallowing Assessment
of Saliva in other clinical settings. However, in
order for the Swallowing Assessment of Saliva to
obviate endoscopic evaluations we recommend fur-
ther studies investigating the validity and reliability
in other clinical settings.
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Clinical message
The Swallowing Assessment of Saliva,
which is based on the Facial-Oral Tract
Therapy approach, is a simple, reliable
and sensitive assessment for detection of
aspiration risk.
Conflicts of interest
Annette Kjaersgaard is a certified F.O.T.T.® instructor
and regularly conducts F.O.T.T. courses. We certify that
all financial and material support for this research is
clearly identified in this article and the article on the rand-
omized study.
Funding
This study was supported by the Danish Association of
Occupational Therapists [FF 2 13 – 5].
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