An Oral Periph Exam: The Who, What, and How

The purpose of an oral periph exam is to look at the range of motion, coordination, strength, and appearance of the oral mechanism. In more simple terms, it evaluates the structure and function of the mouth for speech production and/or swallowing. It is generally done as a part of speech and language evaluations. 

The exam can be called many different titles: oral mech, oral mech exam, oral peripheral exam, oral periph exam, or oral periph. It’s all the same!

Who might give an oral periph?

It is typically done as part of a speech and language evaluation by a Speech-Language Pathologist (SLP). It’s done on both pediatric and adult clients. For pediatric clients, it is typically done as part of an articulation, language, or feeding evaluation. For adults, it’s typically done as part of a swallowing, voice, or speech evaluation following a stroke, head injury, other neurological change, or voice concern. It is sometimes done as part of an accent modification evaluation before assessing articulation.

In addition to SLPs, an oral periph may be done by a dentist, oral surgeon, doctor, otolaryngologist (ENT), or other medical professionals. View my template on Teachers Pay Teachers.

What structures of the oral periph do you evaluate?

Everything that is used for speech production:

• Lips
• Teeth
• Tongue
• Mandible (lower jaw)
• Hard and Soft Palate
• Face
• Voice

How do you evaluate the oral mechanism?

To keep it simple, if the structure moves, you want to evaluate the range of motion, coordination, strength, and appearance. If it is stationary, you want to evaluate its appearance. Here is an overview of how to evaluate each structure:

*Disclaimer: This is not meant to be diagnostic in nature nor is it an all-inclusive list of potential implications of findings. It is meant to be a general guide for completing an oral periph exam. All oral periph exams should be tailored to the client’s needs and the purpose of the evaluation.

Materials needed:

Before getting started, make sure to gather everything needed to complete the evaluation as soon as possible. Your time is limited (and if you are working with a pediatric client, the attention span is very limited).

Materials recommended: an oral periph form or something to take notes on, pen, light, and timer. Optional: gloves and tongue depressor. The two latter are nice to have but not a must-have. Additionally, they may scare small children as they associate these with doctors, nurses, shots, etc. If you choose to use gloves, only use one and place it on your non-dominant hand. This will leave your dominant hand free for writing and you won’t have to worry about cross-contamination by touching the client’s mouth with the glove and then your pen with the glove… you get the point.

Face:

Moving from biggest to smallest, start with evaluating the face. To assess the appearance, face the client and look at the:

• Overall appearance
• Symmetry
• Spacing of eyes
• Head size
• Tone
• Facial expressions

If any of the above are not within normal limits, in children it could be indicative of a chromosomal abnormality or muscle weakness. In adults, it could be indicative of a neurological impairment or muscle weakness.

Mandible:

To assess the range of motion, start by having the client open and close their mouth. To assess the coordination, have the client open and close their mouth several times rapidly. The jaw should move up and down easily, without any popping or discoordination. To assess the strength, add a little resistance under the client’s chin with your hand.

Since there is no side-to-side movement in speaking or eating, only assess the movement vertical movement (up and down).

Lips:

First, notice the appearance of the client’s lip posture at rest. If they are open, the client may be an open-mouth breather. If there is drooling, the client may have labial weakness or poor saliva control. Drooping could be indicative of muscle weakness or a neurological impairment.

To assess for range of motion, have the client smile and then pucker. For coordination, have the client do these two motions together 3 times. To assess for strength, have the client do a lip pop and listen for the sound of a good seal. Then have the client puff their cheeks out with air and hold for at least 3 seconds. A decrease in range of motion, coordination, or strength could be indicative of muscle weakness or a neurological impairment.

Teeth:

First assess the presence and appearance of the teeth. Depending on the client’s age or dental hygiene, they may be missing teeth or be edentulous (having no teeth). Also, look at the client’s dental occlusion, or bite. The types of bites, or dental malocclusions, are:

Overbite: in which the top teeth extend past the bottom teeth
Underbite: in which the bottom teeth extend past the top teeth
Open bite: in which there is no contact of the top and bottom teeth, leaving a gap

Concerns regarding the dental occlusion could be due to thumb sucking, tongue thrust, Clefting, or a large or small oral cavity. Dental malocclusions could impact articulation of speech sounds or feeding (for example, with an open bite, the client may not be able to bite into certain textures). It could also affect the jaw over time. Clients should be referred to a dentist for an evaluation and recommendations.

Tongue:

The tongue can do so much and is very important for eating and speaking so there is a lot to assess here!

First, have the client stick their tongue straight out and assess the appearance of the tongue: size, color, and frenulum. A tongue that is too large or too small could be due to a chromosomal abnormality and impact speech production. A tongue with a grayish or bluish color could indicate muscle weakness. A frenulum that is too long could limit tongue motion and impact articulation of speech sounds. If there is any deviation to the left or right side, this could be indicative of muscle weakness or neurological impairment. The tongue will deviate towards the weaker side because it’s not able to match the extension, or force, of the stronger side.

Then assess the range of motion of the tongue by having the client move the tongue up, down, left, and right both internally (inside of the mouth) and externally (outside of the mouth). This is to emulate movement for not just speech production but also eating. Think about when you have ice cream dripping down your chin or peanut butter stuck to the roof of your mouth.

To assess the coordination, have the client move their tongue left and right (side to side) several times rapidly and then circle around the lips two times. To assess for strength, have the client move the tongue up, down, left, and right and add a slight resistance with a spoon or tongue depressor. A decrease in movement or strength could be indicative of muscle weakness or neurological impairment.

Hard and Soft Palate:

The hard and soft palates make up the roof of the mouth. First, have the client open their mouth and assess the appearance of the palate. Each person’s mouth size and shape are slightly different but the hard palate is at the front of the mouth and goes to about where the back teeth end. The soft palate is lighter in color and starts around where the back teeth end. With a light, look at the overall appearance, color, length, width, and symmetry of the hard and soft palates. A palate that is a bluish or grayish color could be indicative of Clefting. One that is abnormally long or wide could impact the resonance or articulation of speech sounds. A palate that is asymmetrical should be indicative of a chromosomal abnormality or facial injury.

The hard palate doesn’t move but it is an important structure. With the soft palate, there are two additional structures to check out. First, look at the client’s tonsils. Some clients may have had them removed. Clients with large tonsils may have issues with resonance. Also, check the uvula, a.k.a. “hangy down thing” in the back of the throat that no one knows what it is called. First, look at the appearance of the uvula at rest.

Some clients will have a bifid uvula which will look like an upside-down heart. This does not impact anything related to speaking or swallowing; it’s just an interesting observation. Then assess the range of motion of the uvula and soft palate during phonation. Have the client say ‘ahh’ for several seconds. The soft palate and uvula should raise slightly. If the uvula deviates to either side, this could indicate muscle weakness or neurological impairment.

Voice:

Now it’s time to assess the speech mechanism in action. Have the client hold a sustained ‘ah’ sound for at least 14 seconds without stopping or taking a breath. Then have the client do the same thing with the voiced and voiceless speech sounds: /s/ and /z/ for at least 20 seconds each. If the client is not able to hold the sounds for the expected length of time, this could be indicative of muscle weakness, poor breath support, or neurological impairment.

If the client is verbal, engage them in a short conversation and listen to the resonance, pitch, vocal quality, and volume of their voice. A nasal resonance could be indicative of issues with the soft palate. Issues with pitch, volume, quality, or loudness could be indicative of neurological impairment or structural abnormality. If these are noted, refer the client to an ENT for further evaluation.

Diadochokinetic Rates:

Say that three times fast! One of the biggest indicators of difficulty with motor planning in both pediatrics and adults is diadochokinetic rates (DDK). DDK is used to assess the coordination of all of the articulators in rapid speech movements, which is important for speech production.

First, assess rates in successive patterns with labial, alveolar, and velar sounds by having the client say “puh” rapidly as fast as they can for 5 seconds. Count the number of productions. Have the client do this again with “tuh” and “kuh” for 5 seconds each. Then have the client say these sounds in an alternating sequence “puh-tuh-kuh” rapidly for 5 seconds. Count the number of productions. The expected number of productions in 5 seconds is 25r-35r for successive movements and 13r-37.5r for alternating movements (r= repetitions). DDK is not assessed in children under the age of 6.

How do you write up your findings?

Once the oral periph is complete, you must write up your findings for your records as well as the client. See below for my report template for oral periph findings that you can copy and paste into your reports. Also, check out my oral peripheral examination template. Happy evaluating!

View my template on Teachers Pay Teachers.

Oral Peripheral Examination

An oral peripheral examination was administered to evaluate the structural and functional integrity of <Client Name>’s oral mechanism for speech production.

The results are as follows:
Face: Overall appearance, symmetry, and tone appear to be within normal limits. OR
<Describe characteristics>

Jaw: Range of motion and strength appear to be within normal limits. OR
<Describe characteristics>

Lips: Range of motion, coordination, and strength appear to be within normal limits. OR
<Describe characteristics>

Teeth: Occlusion and structure appear to be within normal limits. OR
<Describe characteristics>

Tongue: Range of motion, coordination, and strength appear to be within normal limits. OR
<Describe characteristics>

Hard Palate: Structure and symmetry structure appear to be within normal limits. OR
<Describe characteristics>

Soft Palate: Structure, symmetry, and mobility appear to be within normal limits. OR
<Describe characteristics>

Diadochokinesis (DDK):  <Client Name>’s ability to coordinate the production of syllables in rapid succession (“papapapa”) and rapidly alternate speech movements (“pataka”) is within normal limits. OR
<Describe characteristics>