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When is an oral mech exam used?

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exam of a client's oral cavity and surrounding area is a routine part of every speech-language evaluation

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Why is an oral mech exam used?

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may help shape a theory of etiology, diagnosis, and progress for change and provide a direction that the treatment should take

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What are the objectives of an oral mech exam?

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compare STRUCTURE and FUNCTION of the oral-facial mechanism, determine if problems that exist ARE or ARE NOT related to the speech disorder, make referrals to other necessary professionals if needed

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Structure of oral mech

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normal structures of the lips, tongue, teeth, hard palate, and soft palate and their relationship to each other - evaluate if problems with the physical structure interfere with speech production

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Function of oral mech

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rate, accuracy, and coordination of structural movement during speech production

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Function of oral mech - ROM

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evaluates range of movement - how far the tongue can protrude

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Function of oral mech - Duration of movement

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how long a single or repeated movement can be sustained

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Function of oral mech - Strength of movement

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how well can structure achieve and maintain a position when an external force is applied (i.e. resistance)

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Function of oral mech - Symmetry of movement

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how symmetrical are structural movements

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Function of oral mech - Ease of movement

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how easy is the movement for client

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Function of oral mech - Rate

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how fast/slow is the movement

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Problems with functional adequacy

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suggest possible neuromotor problems

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Functional adequacy

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compare speech and nonspeech movements; may have normal structure but poor function, may have abnormal structure but adequate function

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Materials/Equipment needed

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flashlight, tongue depressor; flavored, suckers (individually wrapped), stop watch, gloves (TWO for each hand), soap/water, mirror, cotton gauze, nasal mirror (check for velopharyngeal incompetence), gown or mask, bite block (evaluate client with strong bite reflex), peanut butter or applesauce, cup, crackers or cookies, forms - type of client (cleft palate or language disorder) or your experience and other specialized forms

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Before you begin oral mech exam

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establish rapport with client, explain what you will be doing and why, be creative with small children to get in their mouths, be aware of cultural issues

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Face symmetry

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observe facial features (forehead, eyes, nose, lips and jaw) at rest and during movement - report R/L droop

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Ptosis

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eye drop

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Face function

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ask client to: open mouth as wide as possible, raise both eyebrows, wrinkle forehead, close both eyes tightly; observe mouth breathing (open mouth may be hyponasal due to restricted passageway or may be due to anterior tongue placement)

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Jaw

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ask client to open/close mouth, observe: ROM, symmetry, movement, TMJ noises, pediatrics - chewing issues (lateral vs. rotary movements)

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Jaw - Bite Reflexes; Tonic

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strong, abnormal closure of jaw with tactile input to the biting surfaces; releases may be difficult (may be elicited from biting surface of teeth or gums, interferes with feeding and oral exploration)

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Dentition (teeth)

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significant dental deviations can be the cause of a spech disorder, especially with the following sounds: /f,v,th,s,z,sh,zh/

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Teeth cont'd

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many people develop compensatory speech patterns and may not exhibit speech problems, helpful to know names of teeth and when permanent teeth emerge, observe overall condition of teeth/hygiene, assess occlusion and bite: may have combinations of occlusion and bite deviations

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Teeth-Occlusion

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(molar relationship) - the relationship between upper and lower dental arches (observe while client bites down on back of teeth and smiles)

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Class I - Normal Occlusion

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lower first molar is half a tooth ahead (in front of) the upper first molar

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Cusps (points)

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first upper molar should fit between the two anterior and posterior cusps of the lower molar

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Class II - Malocclusion

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lower dental arch (or mandible) is too far back in relation to upper arch or maxilla; chin may look receded when mouth is closed, not the same as an overbite

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Class III - Malocclusion

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Mandible is too far forward in relation to maxilla; lower dental arch overlaps upper

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Bite

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relative positions of upper and lower anterior teeth (incisors)

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Openbite

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upper and lower anterior teeth do not make contact (incisors, cuspids, and bicuspids) when in normal occlusion; may be due to tongue position, swallow patterns, atonic lips, pathology of nasal passages

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Overbite

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excessive overlapping of the upper anterior teeth over the lower anterior teeth (teeth touch but overlap); normal-upper central incisors covers 1/2-1/3 of lower central incisors

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Crossbite

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lateral overlapping of upper and lower dental arches; lower jaw appears to be located to the right or left of a normal central position

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Overjet

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excessive horizontal projection of the upper incisors in front of the lower incisors

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Diastemia

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space between teeth

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Endentulous space

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missing tooth or teeth

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Supernumerary

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extra teeth

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Obturators and palatal lift

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dental appliances used for VP

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Lips Structure

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look for symmetry, contour, condition, adequate amount of tissue, scar tissue, closure at rest, drooling

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Lips Function - Nonspeech Movements

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Static movements and reciprocal movemtns

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Static movements

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movements that are made and then held in place (sustained postures); retract lips to each side unilaterally, retract lips bilaterally

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Reciprocal movements-doing maximum opposites

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protrusion and retractions (pucker and smile repeatedly), upper and lower lip approximations - open and close lips /p^, p^, p^, without sound/

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Lips Function

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observe speed (5-6 repetitions per second), ease, symmetry, duration

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Lip Strength

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ask client to puff each cheek out separately, ask client to puff out both cheeks (press each cheek gently, can client maintain the seal?), ask client to provide resistance to a tongue blade (hold tongue blade between lips), test speech movements /ui ui ui ui/ observe protrude-retract sequence, /p^ p^ p^ p^/ observe during diadochokinetic speech task

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Diadochokinetic Speech Rate

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Children - 3-6/second; Adult - 6-7/second

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Gray tongue color

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muscular paresis or paralysis

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Bluish tongue color

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excessive vascularity or bleeding

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Whitish hard and soft palate borders

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submucosal cleft

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Dark or translucent hard palate

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palatal fistula or cleft

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Dark spots

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may be cancer

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Tongue

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Observe at rest; size (relation to mouth),

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Flaccid tongue

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appears larger, may have crease down middle

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Hypercontracted tongue

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seen in spastic CP

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Macroglossia

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possible endocrine disorder

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Tongue Symmetry

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both sides uniform in appearance

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Scalloped Tongue

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common, indicates tongue resting inside upper dental arch, pressed against side teeth (desired position)

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Tongue

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observe abnormal movements (at rest and protruded); spasms, writhing, fasciculations (involuntary twitching)

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Palpate Tone

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UMN lesion - increased tone, rigid LMN lesion - decreased ton, flaccid

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Tongue - Lingual Frenum

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observe, note during tongue protrusion

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If short, frenum is attached too far forward and restrictive, indicated by:

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tongue appears thin and flaccid, tongue dorsum may be humped as attempts to compensate, heart-shaped anterior - frenum inhibits midline movement, white color of frenum - high in fiber and non-elastic (should be pink)

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Tongue

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assess productions of /s, n, t, and d/

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Tongue Function

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perform movements with head in midline and at neutral position, observe protrusion

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Tongue Excursion

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deviates to side of weakness lesion - LMN; weaker half cannot match extension of stronger half, deviates to opposite side of lesion - UMN; no protrusion - bilateral lesion

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Tongue Function cont'd

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ROM, speed of motion, strength -resistance (apply opposing pressure with tongue blade)

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Tongue Function cont'd

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ask client to...protrude and retract tongue (deviations, ROM, speed), Lateralize tongue tip to right (excursion, ROM, strength), Lateralize tongue tip to left (excursion, ROM, strength), Lateralize tongue side to side to assess (rate, ROM, accuracy, smoothness, coordination, consistency), elevate tongue tip to alveolar ridge (type movement, ROM, strength), move tongue tip down (type movement, ROM), rotate tongue around mouth opening to assess (accuracy, coordination, smoothness), assess tongue strength, mandibular assistance, encourage client to perform tongue movements without touching lips or teeth

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Tongue Thrust-orofacial myofunctional disorder

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tongue moves forward abnormally during swallowing, may also lie too far forward in an anterior position during rest or protrude between the upper and lower teeth during speech or at rest

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Tongue Thrust-persistent forward tongue position and lingual protrusion may result in:

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feeding/swallowing problems, orthodontic problems (may change shape of upper teeth and lower jaw), misarticulations (may be related to distortions of s, z, sh, zh, ch, j or interdental t, d, n, l

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Tongue Thrust Causes

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hereditary - shape of mouth, strength of oral-facial muscles, arrangement and number of teeth allergies, enlarged tonsils and adenoids (breath with mouth open, tongue flat and forward, lip muscles may lose strength and tone) excessive thumb, pacifier, or finger sucking lip and fingernail biting neuromuscular disorders

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Tongue Thrust-SLP Role

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id, referral to myofunctional specialists, provision of services if have required knowledge and skills in: myofunctional therapy, evaluation of tongue thrust should be interdisciplinary, as appropriate, including: SLP, orthodontist, dentist, otolaryngologist, pediatrician, allergist

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