Raymond Fong, Mavis S. M. Chan, Pipa H. L. Yau
5 min
Understanding masticatory performance is essential for diagnosing oropharyngeal dysphagia and monitoring the effectiveness of swallowing interventions. The Test of Masticating and Swallowing Solids (ToMaSS) is a quantitative, non-instrumental tool that measures four key parameters: number of bites, number of masticatory cycles, number of swallows, and total ingestion time. While ToMaSS has been validated globally, normative data are highly dependent on the specific test food used, as mechanical properties like hardness and salt content influence chewing behavior. This study aimed to provide local normative data for the Chinese Asian population using the Pacific Saltine Cracker, a commonly used solid food in Hong Kong clinical practice.
The researchers conducted a cross-sectional study of 247 healthy adults aged 21 to 95. Participants were screened to exclude those with dysphagia, salivation issues, or oro-motor deficits. Researchers recorded participants consuming half a piece of a Pacific Saltine Cracker and analyzed the video footage to determine the four ToMaSS parameters. Additionally, the study assessed the impact of posterior functional tooth units (FTU) on masticatory performance to determine if reduced occlusal contact correlates with changes in ingestion behavior.
The study found statistically significant effects for both age and gender. Generally, males exhibited fewer bites, fewer masticatory cycles, fewer swallows, and shorter ingestion times compared to females. Advancing age was positively correlated with increased masticatory cycles and longer ingestion times, though it did not significantly affect the number of swallows. While the study examined the role of posterior functional tooth units, the results suggested that reduced posterior occlusal contact only weakly correlates with most ToMaSS parameters, indicating that tooth loss may have a limited impact on masticatory performance in this healthy cohort.
These findings provide clinicians in Hong Kong and similar regions with a standardized benchmark for evaluating swallowing function. By using locally relevant test foods, speech-language pathologists can more accurately detect functional changes in swallowing and monitor the trajectory of patients with dysphagia, ensuring that clinical assessments are both reliable and culturally appropriate.
Alex: What about teeth? Intuitively, you'd think the number of working back teeth would be a major factor.
Sam: You'd expect that, and it's a reasonable assumption. The study looked at what researchers call "Functional Tooth Units"—essentially, the number of pairs of upper and lower back teeth that actually make contact when you bite down. Those are the teeth doing the grinding work. But the study found only a weak connection between that count and the ToMaSS scores. So while having fewer functional back teeth might make chewing somewhat harder, it doesn't appear to be the dominant factor driving how someone performs on this test.
Alex: That's a bit counterintuitive. So who did they include in the study to make sure the baseline was clean?
Sam: They were careful about that. Anyone with a known swallowing difficulty was excluded, as was anyone with xerostomia—a condition where the salivary glands don't produce enough moisture. Saliva is essential for softening food and forming that bolus, so someone with chronic dry mouth would naturally struggle with this test for reasons unrelated to their swallowing mechanics. Removing those participants meant the data reflected genuinely healthy function.
Alex: And how did they make sure two different clinicians watching the same patient would record the same numbers?
Sam: They used a statistical measure designed exactly for that question. Imagine two referees watching the same football play and then independently writing down what they saw—a good officiating system is one where they almost always agree. The statistical equivalent is called an Intraclass Correlation Coefficient, and it produces a score reflecting how closely two observers' readings match. In this study, the agreement was rated as excellent, which means the test produces consistent results regardless of who's administering it.
Alex: So the real contribution here is giving clinicians in this part of the world an accurate, locally grounded benchmark.
Sam: That's it exactly. By standardizing both the food and the measurement process, clinicians now have a reliable reference point to identify when a patient's chewing and swallowing falls outside the typical range for their own community. A plain cracker becomes a precise diagnostic instrument.
Alex: Though I imagine these numbers aren't meant to be hard cutoffs—like, scoring one point below the average doesn't automatically mean something is wrong.
Sam: That's an important distinction. These values aren't absolute diagnostic thresholds. They're more like a flag—a signal that a patient's performance is unusual enough to warrant a closer look. The clinician still has to interpret the result in context.
Alex: Are there any clear gaps the researchers themselves flagged?
Sam: One notable limitation is the sample size for participants over eighty. There simply weren't enough people in that age group to draw confident conclusions, so the researchers advise caution when applying these benchmarks to the oldest patients. That's a gap future studies will need to fill.
Alex: So it's a meaningful step, but one that still needs to be built on.
Sam: Exactly. The researchers point to possibilities like AI-assisted video analysis, which could eventually automate the counting process and make the test faster and even more consistent. For now, this study provides a solid, evidence-based foundation for more localized and accurate care.
Alex: A cracker and a stopwatch, doing real clinical work. Thanks for listening to ResearchPod.