Diet and the Edentulous Patient
Rarely does an article rankle as much as "No Teeth, No Dentures: Is a Regular Diet Possible" in The ASHA Leader (April 2013), and we disapprove of the Leader's inadequate vetting of the information.
The problems start with, "How do we determine the safest diet texture following a bedside swallow evaluation?" Because bolus flow characteristics cannot be determined from a bedside evaluation, it is impossible to recommend "...alternating solids and liquids or performing a chin tuck," determine supraglottic "...signs and symptoms of laryngeal penetration...," or have the "...patient perform a strong and timely voluntary (italics ours) cough" for a (undetected) solid food bolus "... lodged in the larynx ...." And, since there is no such thing as "... laryngeal stage of the swallow," how can this non-entity be improved?
Interestingly (alarmingly?), there was no mention of assessing aspiration risk! Although 90º positioning is preferred, no research supports that <90º results in degraded mastication. We know people eat solids without teeth. But they are home, not sick, and maintain adequate functional reserve to bite, masticate and swallow successfully. Our great fear is recommending solids to hospitalized, sick and deconditioned edentulous patients. They are not the same person physically.
Lastly, "Is a regular diet possible?" was not answered. Neither "Ben's" diet (puree) nor "Dorothy's" (mechanical soft) was a regular diet. Lastly, a diagnosis of "aspiration pneumonia" could be food-related or simply pneumonia of unknown etiology. We spend our professional lives practicing evidence-based medicine for optimal patient care. This article does the opposite.
Steven B. Leder, New Haven, Conn.; James L. Coyle, Pittsburgh, Pa.; Debra M. Suiter, Memphis, Tenn.; Cathy Lazarus, New York, N.Y.; Jeri A. Logemann, Evanston, Ill.
Amanda Matloff, author of "No Teeth, No Dentures: Is a Regular Diet Possible?" responds:
Thank you for your feedback. This type of discourse benefits clinicians as they advance their education and working knowledge and apply it to their practice.
The article should have read "pharyngeal phase of the swallow," not "laryngeal stage of the swallow," and has been corrected online.
Secondly, the feedback indicates that the characteristics of the swallow and recommendations, as described in the article, cannot be determined from a bedside swallow evaluation. The article made the assumption that the speech-language pathologist had access to the objective information from the video swallow study, along with the bedside swallow evaluation prior to making the recommendations. This assumption should have been clearer by changing the leading question to "How do we determine the safest diet texture following a bedside evaluation and video swallow study?"
In response to leaving out "assess aspiration risk," the intent was not to point out obvious evaluation measures, but to give clinicians less obvious considerations beyond the objective evaluation—such as assessing motivation or alertness during meals—to best serve patients. This information may be helpful during treatment.
It is crucial that evidence-based practice and objective analysis be of utmost importance in our field and guide the decision making process. The intent of the article was to not to do the opposite, but to encourage clinicians to appreciate the patient from the broadest perspective over the course of care—for example, to keep an eye out for differences in swallow function that arise from factors such as lethargy or motivation.
College Students on the Spectrum
I read with great interest the cover story in the April 2013 issue, "Spectrum of Opportunities," regarding the role of speech-language pathologists in university programs for college students on the spectrum. I applaud you for writing this article for our membership as it addressed timely and important issues for those of us working in higher education settings, as we develop programs to meet the needs of this growing population.
I would like to alert members of the profession to the existence of other innovative programs around the country with significant participation of speech-language pathology faculty and programs. For example, last year Brooklyn College of the City University of New York piloted an Interdisciplinary Collaborative Support Services program, an initiative that involves the college health clinic, disabilities office, personal counseling center, academic learning center, career counseling center and, of course, the speech-language-hearing center, all located on our urban campus.
The program has continued this year. For information, please visit the Brooklyn College posting or contact me at firstname.lastname@example.org.
The Art of Conversation
This is a plea to all my fellow SLPs! Please, please, please continue to be a proponent of healthy communication by not allowing the technical devices of the day to interrupt the flow of normal conversation.
I am writing as I reflect on an article from the March 2013 ASHA Leader, "Document it on the Spot." As a school-based SLP, I too feel the weight of increasing demands for documentation, billing and excessive paperwork. I urge you (and myself) to remember our purpose. If we don't advocate for communication, who will? I hope we all find more effective ways to manage our time. We can do it!
Black Mountain, N.C.