The “Gold Standard” in dysphagia assessment: Clinical swallowing evaluation, instrumental evaluation methods and artificial intelligenceThe importance of instrumental assessments such as Videofluoroscopic Swallow Study (VFSS), Fiberoptic Endoscopic Evaluation of Swallowing (FEES), and Manometry in the study of swallowing has long been recognized in speech-language pathology. In eligible patients, these tools may also play a relevant role in guiding a more targeted and effective intervention1-7.
Among instrumental assessments, the VFSS was the first to be developed as a method for evaluating dysphagia, around the 1970s. In 1979, for example, Logemann et al.2 were already conducting studies using VFSS as a pre- and postoperative assessment in three patients with head and neck cancer. The FEES emerged later as a less invasive alternative4,8.
The first scientific studies published on FEES date back to the early 1980s, initially focusing on the assessment of esophageal and gastric disorders and later correlating with swallowing3,4. By the 1990s, authors were already seeking to compare VFSS and FEES, aiming to understand their reliability and applicability in different patient groups4.
Around the same historical period, authors such as Asoh (1978)5, Dodds (1987)7, Dooley (1988)6 and Dantas (1990)9 conducted various studies using manometry and electromanometry, aiming to understand the effects of changes in bolus viscosity on pharyngeal and esophageal peristalsis.
With technological advances, instrumental swallowing assessments-particularly the VFSS-came to be regarded as the “gold standard” for the diagnosis of dysphagia. In 2008, Logemann10 had already stated that the use of VFSS was fundamental for the study of swallowing and for evaluating the effectiveness of therapeutic procedures, such as maneuvers and modifications in the consistency of foods and liquids.
It is evident that certain aspects of interpreting an instrumental assessment are susceptible to human bias and subjectivity, resulting in significant variability. More general aspects, such as the presence or absence of aspiration and residue, are less complex to characterize. However, more specific measures-such as the identification of soft and hard structures, their distances and displacements, and the temporal sequence of events-require greater clinical and scientific experience in analyzing the images11-14. In this context, artificial intelligence (AI) emerges as a potentially valuable tool14.
In a 2025 study, Sanjeevi et al.14 reviewed the most advanced tools using AI to analyze VFSS in the assessment of swallowing disorders and to support clinical decision-making. The findings reported significant advances in areas such as the description of the pharyngeal phase, segmentation and identification of the bolus and the hyoid bone, and the detection of penetration and aspiration. However, a fully automated and unified AI system for comprehensive examination analysis has not yet been developed.
Naturally, there has been a massive investment in instrumental and automated assessments, accompanied by a consequent devaluation of the clinical evaluation, particularly within the context of scientific studies. While the need for standardization and objective measurement of a function for its quantification and research analysis is understandable, it is not feasible to discredit a clinical practice that is evidence-based and performed daily by thousands of speech-language pathologists across multiple countries.
It is not possible to determine an exact percentage of patients with dysphagia who undergo instrumental assessments in daily practice. The decision to perform an assessment depends on multiple factors, including the severity of dysphagia, the origin of the swallowing complaint (oral, pharyngeal, and/or esophageal), the clinical condition and its socioeconomic context, resource availability, and the professional’s judgment. Even when considered the “gold standard,” in Brazil, these instrumental assessments are performed only in selected cases, whether in public or private services. Furthermore, there are numerous regions and healthcare centers where instrumental evaluations are not available.
The vast majority of speech-language pathology assessments and interventions for dysphagia in Brazil are conducted without the use of instrumental assessments. Does this mean that such interventions are of low quality or provide no benefit to the patient? Can there be a “gold standard” intervention without an assessment that is considered the “gold standard”, according to the international literature?
In 2022, Doan et al.15 conducted a systematic review with meta-analysis aimed at investigating the prevalence and methods used in the assessment of oropharyngeal dysphagia in older adults. The authors described that, in clinical practice, a comprehensive swallowing assessment generally includes: a review of the patient’s psychosocial and medical history (detailed anamnesis), self-reported symptoms and swallowing-related complaints, cognitive-linguistic screening, a complete intra- and extra-oral examination, assessment of orofacial motricity, tests with different food and liquid consistencies when possible, review of habitual dietary patterns, and therapeutic trials. The authors stated that the prevalence of dysphagia in older adults is high; however, the use of non-validated clinical assessment tools to report dysphagia could underestimate its true prevalence.
It is understandable that the use of validated clinical instruments can be a positive factor for both clinical practice and research. However, the question at this point would ideally be guided by the following: is the use of validated tools truly necessary during the clinical assessment of all patients, or would clinical experience and evidence-based intervention be equally-or even more-important?
In 2021, Costa et al.16 conducted a study aimed at characterizing the profile of speech-language pathologists working in healthcare services across Brazil and examining whether years of professional experience, specialized training, and experience in dysphagia contribute to a more accurate interpretation and application of the Blue Dye Test. The authors concluded that specialized training and ongoing health education practices determine clinical excellence in speech-language pathology, particularly in the care of more severe patients, such as those who are tracheostomized, post-intubated, or at risk of aspiration.
In a systematic review conducted in 2024, Pizzorni et al.17 analyzed and synthesized the available evidence regarding the application, safety, efficacy, and protocols used in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in children. FEES was shown to be a safe, accurate, and generally feasible assessment in the pediatric population with suspected dysphagia. However, there is still no consensus on the optimal FEES protocol for clinical practice and research. In the pediatric population, clinical swallowing assessment appears to be considered paramount in the literature.
In medicine, clinical assessment is essential, and it is already widely accepted that the request for complementary evaluations-such as laboratory tests, imaging, and instrumental assessments-must be rigorously selected from the perspective of resource management, cost control, and minimizing patient exposure to potentially harmful agents. So why, in speech-language pathology, could the clinical swallowing assessment performed by a specialist not also be considered a “gold standard”?
It is still common to find speech-language pathologists promoting the concept that the ideal approach would be to recommend instrumental swallowing assessments for all patients presenting with symptoms of dysphagia. This appears to be a misguided notion, based primarily on an international and research-based context.
We believe that technological advancements, AI, and validated protocols can contribute significantly to the field of dysphagia. However, it becomes essential to place greater value on clinical swallowing assessment performed by a qualified professional. Fundamentally, it is necessary to provide and promote continuing education, as well as the development of robust and multidisciplinary guidelines that are contextualized to the realities of different regions in low- and middle-income countries.
Standards and assessment protocols based on the practices of international research centers are unrealistic in the context of most of Brazil and the world. The devaluation of clinical assessment undermines the profession and diminishes our practice and expertise in dysphagia. Instrumental assessments are highly relevant; however, as in any area of healthcare, they should be recommended according to the judgment of a specialist professional.
Even with the numerous advancements provided by AI, professionals remain essential in recommending and performing instrumental assessments, as well as in interpreting and stratifying the generated data. The careful evaluation by a specialized speech-language pathologist, with experience and interdisciplinary support, and, when necessary, the performance of instrumental assessments, elevates the clinical swallowing assessment to a “gold standard” as well.
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