Two edentulous patients are on your caseload for dysphagia evaluations. Ben receives a platter of pureed steak and vegetables, and his family asks you why he was placed on a puree diet. After all, he was eating regular foods up until his most recent hospital admission, when he was diagnosed with aspiration pneumonia. On the other hand, Dorothy's tray arrives with a plate of regular steak and salad. Her family beams and informs you that she's always consumed regular textures without dentures. A thorough chart review however, reveals a history of aspiration pneumonia. Can both diet recommendations be correct?
Let's face it: We don't always see a sparkling set of teeth smiling back at us when we perform oral mechanism exams. We might see beautiful gums, with one lucky tooth revealed as the patient demonstrates /ah/. We might see a lower denture rotating 360 degrees as the patient performs a lingual lateralization task. We see patients who still have their own teeth, others who are missing teeth, have full or partial dentures, or have an edentulous oral cavity—one with no teeth at all.
And of the edentulous patients who have dentures, many refuse to wear them—perhaps because the dentures don't fit correctly, or just an inherent preference to go au natural. Other patients can't afford new dentures or are waiting for dental consultations. In the meantime, the speech-language pathologist must conduct a swallowing evaluation, whether bedside or instrumental.
SLPs then make recommendations, often consulting the physician, dietitian and family in the process. But what else should we consider during the initial evaluation, particularly for an edentulous patient? How do we determine the safest diet texture following a bedside swallow evaluation? Here are a few practical tips to consider:
- Cognition and motivation. Does the patient have the cognitive ability to follow and recall directions to use compensatory swallowing strategies, which are required for an upgraded diet level? A patient with impaired cognition who requires moderate verbal cues during oral intake may become frustrated and less motivated when directed in compensatory strategies, such as alternating solids and liquids or performing a chin tuck. Also, a patient may be more motivated to consume more with a mixed-consistency diet versus a single-texture diet.
- Fatigue. Often, how the patient acts during mealtime tells a different story than the same patient's performance during a video swallowing study. The patient may have a functional oral stage during the study, for example, but during an actual meal shows prolonged and inadequate chewing, poor anterior-posterior transit time and weak tongue control. These differences may be due to, for example, medication interference or fatigue following physical therapy.
- Positioning. During your evaluation, family members might encourage the patient to sit upright for feeding. But when the SLP is not with the patient, does the family still comply with the recommendation? Edentulous patients—especially those with a history of talking during chewing or frequent refusal to sit upright at 90 degrees—may require a diet modification appropriate for actual feeding conditions.
- Laryngeal function. If a patient presents with signs and symptoms of laryngeal penetration, can the patient effectively use compensatory swallow strategies? Or, if an edentulous patient doesn't chew a piece of food properly, and it becomes lodged in the larynx, can the patient perform a strong and timely voluntary cough? The clinician might recommend a diet modification—such as adding gravy to regular foods—or a downgraded diet level to improve the pharyngeal stage of the swallow.
When SLPs recommend the least restrictive diet for a patient, it is important to respect and support the rights of the family and patient. To learn more about patient rights regarding diet level, check out the Pioneer Network Food and Dining Clinical Standards Task Force's New Dining Practice Standards [PDF].
By considering factors beyond the initial evaluation, Ben and Dorothy's diet levels were modified to suit their abilities. Ben continued the puree diet, while Dorothy benefited from a diet downgraded to the mechanical soft level. For other patients, these factors (cognition and motivation, positioning, etc.) may play a more favorable role for the patient, resulting in the ability to safely tolerate a diet upgrade.
Share your findings with the patient, physician and the family. Look out for these factors and keep an open, yet critical, mindset. Your edentulous patients may just surprise you with their abilities.