Inbox: 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 ... Inbox
Inbox  |   June 01, 2013
Inbox: Diet and the Edentulous Patient
Author Notes
Article Information
Swallowing, Dysphagia & Feeding Disorders / Inbox
Inbox   |   June 01, 2013
Inbox: Diet and the Edentulous Patient
The ASHA Leader, June 2013, Vol. 18, 3-4. doi:10.1044/leader.IN1.18062013.3
The ASHA Leader, June 2013, Vol. 18, 3-4. doi:10.1044/leader.IN1.18062013.3
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.
Author's Response
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.
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FROM THIS ISSUE
June 2013
Volume 18, Issue 6