Dentures 101

Though this happened a while ago, this is by far one of my best SLP stories. As an SLP, we learn quite a bit about human anatomy, especially of the mouth and throat. However, in graduate school, they tend to leave out practical information, like how dentures work.

Now, the great majority of the public knows about dentures, or fake teeth. I would put myself in that category, even though I had never worked with dentures prior to this experience. Now, we've all seen the adds on TV for denture adhesive, whether it be the paste or the little mouth-shaped strips. And, by watching those commercials (and presumably reading the directions), one could assume that applying dentures isn't rocket science. Well, not entirely rocket science!

Working in a Rehab facility, I knew that one day I would have to help some cute little old man with his dentures. This fact didn't really bother me....I'm not squeamish, or afraid, or grossed out by much. So, when the day came, I jumped right in.

That morning, I was seeing a cute little old man, Mr. R, right after breakfast for therapy. He had Parkinson's disease, which can greatly effect the volume and clarity of speech, and was very weak. Parkinson's disease, in its later stages, can also effect cognition, and can result in Parkinsonian Dementia. During our therapy session, I was planning to work on memory, volume projection, and the use of clear speech strategies in conversation. As I greeted Mr. R and wheeled him out of the dining room, I noticed that he was pleasantly confused and didn't have his dentures in.

So, we made a side trip to his room, where I planned to get his dentures. The following exchange is best presented in dialogue form. Enjoy!

Me: "Alright Mr. R, lets put your dentures in."
Mr. R: (In a very muddled voice) "No...they hurt."
Me: "Are they too loose?"
Mr. R: "Yes."
Me: "Ok, well, lets put some adhesive on them. Would that make them fit better?"
Mr. R: "Yes."

I proceeded to take Mr. R's dentures out of the container and squirt a line of adhesive on the top plate. I then put the top plate in Mr. R's mouth and held it there for 3-5 seconds. I turned away and began to prepare the bottom plate with adhesive paste.

Me: "Ok, Mr. R, lets put the bottom ones in."
Me: (Turns toward Mr. R to see top plate sitting on Mr. R's tongue.)
Me: "Oh, Mr. R, did they not stick?!"
Mr. R: "asdf oiadf n;akjdnf ;sadsf." (Presumably, "No.")
Me: "Should we try and stick them back up?"
Mr. R: (Shakes head 'no'.) "adsf oiawnefo;nad ;adosfj."
Me: "Ok, lets just take them out."
Me: "Would you like a drink of water to rinse your mouth out?"
Mr. R: "No."
Me: "Are you sure?"
Mr. R: "No."
Me: "Ok...."

I then proceeded to wheel Mr. R back out into the dining room, where I had decided to conduct what was left of our therapy session. We park in a sunny spot next to the window.

Me: "Ok, Mr. R, can you tell me what today's date is?"
Mr. R: (TRIES TO TALK, BUT MOUTH IS GLUED SHUT!) "WA WA WA, WA WA WA WA"
Me: "OH MY GOSH, MR. R, IS YOUR MOUTH STUCK?!?"
Mr. R: (Emphatically nods his head 'yes'.)
Me: "Oh, Mr. R, I am so sorry!"

I then high-tail it out of the dining room and back into Mr. R's room. Once there, I PRY his mouth open with my gloved fingers and desperately try to scrub the denture GLUE from his gums!

Me: "Mr. R, I am so sorry, this is the first time I've ever put dentures in before!"

Then, Mr. R's wife enters the room and immediately starts laughing. wonderful.....

Mr. R's Wife: (Laughing) "You glued his mouth shut, didn't you!"
Me: (Almost crying) "Yes, I am so sorry! I guess I'm not very good at this!"
Mr. R's Wife: (Still laughing) "He wouldn't rinse his mouth out, would he?"
Me: "No, he wouldn't."
Mr. R's Wife: (Still laughing) "He always fights me on that one! You just have to get mean with him. Really, I just need to get him some dentures that fit right!"
Mr. R's Wife: "Don't worry honey, he won't remember it anyway!"

And so ended my very first experience with dentures. Thankfully Mr. R and his wife were good sports and didn't get upset. I can only imagine the explanation I'd have to give to a crabby family. Needless to say, I haven't tried my hand at dentures again!!

And now, some Zelda Wisdom...

The "Definition" of Life ~ I'll warn you now, it's LONG!

For a therapist of any kind, it’s a rare experience to see a patient from start to end. Most of the time, you may see them in the beginning and then they go to another facility. Or, they may be coming to you after already being treated somewhere else. Either way, you never really get the full story and you can’t really appreciate how much progress the patient has actually made.

My place of employment, however, allows me to see a patient from start to finish. The speech-language pathologists (currently there are 4 of us) serve our entire health system. We see patients…

• at the acute care hospital (think “ICU”),
• we see those same patients when they come over to the Rehab hospital (think “not medically ready to go home yet” + “intensive speech, occupational, and physical therapy for three hours per day),
• And we see those same patients again in our outpatient clinic.

So, we will get to see a patient at their worst (usually in the ICU) and then follow them until the end. My first patient that I've followed from beginning to end, may be the most memorable patient I've ever had. I’ll call him “P”.

I first saw P when he was in the ICU. He was 38 years old and had had a MASSIVE stroke. The stroke was so massive that the doctors had to remove part of his skull to allow his brain to swell (which is called a “bone window”). When I met P for the first time, he had a tube in his neck (tracheostomy) so he could breathe. The entire right side of his body was paralyzed and dead. He couldn't point to a picture, he couldn't shake his head yes or no, he couldn't mouth words (when you have a tracheostomy, you must have a special valve on in order to talk…P couldn't even handle that yet), and he couldn't follow basic directions (ex: stick your tongue out), and he couldn't swallow safely (he had a feeding tube in his stomach).

I can’t remember how long P was in the ICU, but I saw him every day. Eventually, he got to where he could point to pictures, nod his head yes and no, and he attempted to follow directions (ex: when I asked him to smile, he would close his eyes). Finally, we got the call he was going over to the Rehab hospital. P had a really long way to go, but at least he was getting started.

I followed P over to the Rehab hospital, where we immediately started working on his voice. He was given the special valve that allows you to talk when you have a tracheostomy (it’s called a Passy-Muir Speaking Valve), but no sound came out. First we tried for an “ahhh”, which wasn't happening. Then, we tried for any noise at all. While we were working on turning P’s voice back on, we had to find alternative ways to communicate. P tried using a communication board, which had pictures he could point to, but he didn't like using it. Then, we gave his an electrolarynx, which is a device you hold to your neck that creates sound waves you shape with your mouth into speech. P couldn't use this, as he was unable to mouth words. So, we did it P’s way…asking yes and no questions to communicate about everything.

After quite a while with no voice, an Ear Nose and Throat doctor was consulted. I feared P’s vocal cords may be paralyzed from his stroke. My fears were confirmed, and I went to P the news. I informed him that we would still try to get his voice back, but it would be very hard (there are very few ways to treat paralyzed vocal cords).

P still had the tracheostomy and the valve and was getting quite sick of them. P had had a very deadly infection in his lungs (MRSA), but that had cleared. So, there was talk about removing his tracheostomy tube and letting the hole heal (so P would breathe normally). Well, P couldn't wait. I came in early one morning and the respiratory therapist yelled to me from down the hall. I ran to him; he was outside P’s room. He held up a really disgusting looking tube and said “he pulled it out.” I was in shock! P’s tracheostomy tube had been stitched in! I bet that hurt! Well, it was a blessing in disguise…the tube did not have to be put back in and P’s hole in his throat began to heal nicely.

Now, at this point in time, P was cleared to eat soft foods with THICKENED liquids. If you've never had the opportunity to taste thickened liquids, be grateful. Just imagine having everything you drink the consistency of cream of chicken soup….yuck!

P’s hole in his neck eventually healed and his swallowing improved enough to where he could drink regular things. He was quite glad for that! All the while this was going on, P was participating in his physical therapy and occupational therapy as well. P could not sit in his wheel chair by himself, for fear he would slouch over and fall out (because of his paralyzed side). P could not stand without being held up by a machine and three people. P could only eat with his left (non-dominate) hand and had to have special bowls and utensils. AND on top of all that, P had to wear a helmet to protect his brain (remember his “bone window” is still open.

Imagine being 38 years old, married with three kids, stuck in a hospital where you can barely eat, can’t talk, can’t walk, are surrounded by old people, and you have to wear a helmet. I think I would die… But, P never gave up.

One day, we had a medical school resident come and observe our therapy (all Med students have to do this) to find out what a speech therapist does. Now, this resident had met P while he was in the ICU. When I told her she would be able to observe his session, she was eager to see how he was. She accompanied me to my session, which was held in P’s room that day, and “barely” observed. When the session was over, and we were walking back to my office, the resident asked me “WHY DIDN'T THEY JUST LET HIM DIE?” I was aghast….how could someone say something so cruel and insensitive! I brushed her comment off and rededicated myself to providing P with the best care possible.

The next piece of news, which was good, came in the form of pain. Now, P had been working with his occupational therapist on ways to reduce the swelling in his dead leg and arm. When you have a stroke, your paralyzed side can swell due to lack of circulation and excessive fluid. P’s foot was especially swollen and painful. His occupational therapist had been working to force his shoe on, and he SCREAMED IN PAIN. She immediately came and found me and brought me to P’s room. She proceeded to mess with his shoe again, and I heard his VOICE for the very first time! It wasn't much, and the method for achieving the voicing was completely unorthodox, but his voice functioned nonetheless!

So, for the next couple of weeks, all of P’s therapists found ways to “turn his voice on”. As we did this, his voice would engage more and more often. Usually, automatic words or phrases would come out (ex: things like “Ow” or “Sh*t”. Some people hounded P for cussing, but those who knew him encouraged it. When a person has a stroke and their speech and language are effected (Aphasia), the easiest words to get out are automatic things that are ingrained in your brain. For men, it’s usually curse words…

Now that we had a voice (yea!) and some automatic speech (double yea!!) coming out, it was time to address P’s verbal communication. Every day, for 1 even 2 hours at a time, we grilled P on automatic speech. We worked hard to count to ten, to say the days of the week, to say the months of the year, to say the ABCs, and to complete the missing word at the end of a sentence. P made progress, but it was VERY SLOW!

By this time, P had been at Rehab for more than two months. The normal Rehab stay for a patient is 2 weeks. P’s insurance funding had run dry and we had to find a way to keep him a little bit longer. One of the benefits of working for a nonprofit hospital is that it’s easier to find funding for patients who need our services. Now, that funding is not limitless, but it is there for the patients who show potential for improvement.

Always in the back of my mind was the comment the resident made about P: “Why didn't they just let him die?” I thought about that a lot and really pondered what the definition of life really is. Could P really call this a life? I couldn't answer that question for him, but it did make me think hard about quantity of life vs. quality of life. P had been given more years in his life, but what about the quality of those years. Catholics (the religion I am) believe that all life is precious, from conception to natural death. We are all given our cross to bear, and sometimes that cross is continued life after tragedy. I’ll never know if P would be better off dead than alive…I don’t think I’d want to know that. What I do know is that the life P has is better because of me and my efforts.

But back to P’s journey. P was making great improvements in his physical and occupational therapy. He couldn't walk and he was still paralyzed, but he was pushing himself in a one handed wheelchair and was using his good side for all his personal care needs. He was even able to transfer from the wheelchair to the toilet with just the help of his wife.

His speech, however, was road blocked. P had managed to get single words out, but those words were usually the wrong ones. Patient’s who have had a stroke and have aphasia (language problems) usually say one word when they mean another. For example, a person may be trying to say “chair” but it comes out as “table.” Or a person may be trying to say “hat” and it comes out as “cat.” P had both of these problems, and man was it frustrating.

It came to the point in time where P had to go home. Home to his small house, out in the country, which was probably too small to move around in a wheelchair in. Home to his wife and three kids he could no longer financially support. Home to a place where he could not communicate his wants or needs without major effort on his part and the part of others. But home, none the less.

We were all sad to see him go. We knew he would be coming back as an outpatient, but somehow that wasn't enough. P had not made the progress we thought he would. Our goal at Rehab is functional independence; P was still severely disabled and dependent on others for most everything.

Again, I followed P to the outpatient setting. In the beginning, he saw all three therapy disciplines (physical, occupational, and speech). And again, he made progress in all areas but speech. One day, I noticed P was about 15 minutes late coming from physical therapy. I was irritated: was the therapist keeping him too long, had P gotten a late start, had P not shown up for therapy at all? I marched over to the outpatient gym on a mission to find him and/or his physical therapist. What I found on the way was one of the most awe inspiring things I have ever witnessed. P was walking down the hall! He was going at a snails pace, using a one-sided walker, and dragging his foot along, but he was WALKING!! I thought, wow, the quality of his life has drastically increased!

P continued to make gains in the walking department. He began walking around his home and insisted on walking in between his therapy appointments (even though we had to end almost 10 minutes early so he’s have enough time to walk!). In the speech department, however, P actually got worse.

The brain is a funny thing. P needed all that brain power to move his legs, keep him steady and balanced, and concentrate on the walking process. Not much was left over for speech.

Now, P’s funding has really run out. He is not eligible for government assistance yet, because he has not been disabled “long enough” and his wife, at her minimum wage job, makes “too much” money. The hospitals assistance for him has also run out; they've been paying for him for almost 4 months. So, we now have two weeks to wrap up therapy and give P a program to work on at home.

If only it were that easy. P is a pro at his occupational and physical therapy home exercises. He is motivated and performs them well. His speech home program is different. I can’t tell if P has lost his will to speak or if he doesn't understand the importance of practicing; either way, he is not practicing at home. I've told P on numerous occasions, when it comes to speech, I can’t fix you. I can only “GIVE YOU THE TOOLS TO FIX YOURSELF.”

So, in the next few days, P will leave us for good. Who knows what will happen to him now. Hopefully, his family will continue to provide for him and he will improve. I pray that is the case. I know I have improved P’s quality of life, but to what extent? And, is that quality worth the added extension? My co-worker, who had also followed P throughout his journey, asked me the other day, “Do you remember what that resident said about P? You know “Why didn't they just let him die?”” I responded “yes, I remember.” She then said, “In some cases, life is more painful then death. In P’s case, that might be true.” I will never know, nor would I want to, if P’s life now is worse than death. What I do know now is that the definition of life is not always clear cut. I pray for P’s continued improvement daily, and I will never forget the impact he’s had on my professional and personal life.

And now, some Zelda Wisdom...

The first man I ever helped - Mr. V

Doing this job (speech-language pathologist), sometimes I ask myself “Is what I’m doing really making a difference?” Sometimes the answer is “no”, but more often than not, the answer is yes. Measuring success in this field is sometimes very difficult. If a patient has cognitive (thinking) deficits, it’s hard to judge whether or not you've really helped them. If a patient has dysphagia (swallowing problems), success is more easily measured.

Patients can have swallowing problems for a lot of reasons, the most common one being stroke. The first man I ever truly, for a fact, helped, however, had swallowing problems because he had been in a car accident.

This man, Mr. V, came to us with two crushed legs and an inability to swallow. A feeding tube had been placed in his stomach so he could receive nutrition, hydration, and medication. If we tried to give him something to eat, he would choke and cough and aspirate (where food or liquids go down into your lungs – VERY dangerous). Usually, we treat swallowing problems with electrical stimulation to the throat. However, Mr. V had an internal defibrillator, so we couldn't use electrical stimulation (it would set his defibrillator off!).

So, we had to treat him the old fashioned way…he had to lie flat on his back and hold his chin to his chest for one minute. He then rested for one minute. That sequence was repeated three times. Then, he touched his chin to his chest 30 times. All of that was done at least three times per day!!! This kind of therapy is hard; it’s hard for the patient and it’s hard for the therapist. But Mr. V, he gave it his all. Mr. V was a fighter…he was a patient of my mother’s (who is a cancer nurse) who got into a car accident on his way home from his last chemotherapy treatment. Talk about bad luck.

Well, long story short, after many weeks of intense therapy, Mr. V was able to safely swallow! Getting someone off their feeding tube (PEG tube) is a big deal in and of itself. But, getting a patient off a feeding tube using this old fashioned exercise method is an even bigger deal. Needless to say, I really felt like I helped a person when Mr. V wheeled himself out of our facility.

I still see Mr. V quite frequently. He still comes to therapy for his legs…he walks with a walker now. Every time I see him, he has a smile on his face and a big hug waiting for me. That’s why…I love what I do!

And now, some Zelda Wisdom...

Hello Again!

Well, I've decided to start blogging again. I've been doing it off and on for about four years on another site, but I've decided to start up again for two reasons. First, I want to remember my patients and the lessons they've taught me. I don't write about them for others; I write about them for me, so that I may have a central place to revisit those memories. I will repost some of the more recent memories.

Second, I need to keep my sanity. I write lots things before I say them. Sometimes I say those written things afterwards, and sometimes I don't. I think this habit of mine will come in handy, especially in the next year, as I plan my wedding. I have been engaged for 9 days so far, and the control freak in me is already showing. I know, for my sake and my fiance's sake, that I cannot become a bridezilla. So, hopefully blogging about this process will make it a little easier (at least on him!).

I tend to personalize much of what goes on around me: the good and the bad. About 4 months ago, while waking through the mall with my fiance, I came across one of those decorative signs in Hallmark. It read, very simply, "Love what you do." That phrase has not left my mind. I want that to be true for me all the time: when I'm at work or with Jon or doing all the other crazy things I do. So, that is the goal, which leads me to my favorite quote of all time: "Yesterday is history and tomorrow is a mystery. We only have the gift of today; that is why we call it the present!" ~ Eleanor Roosevelt

And now, some Zelda Wisdom...