Orofacial Examination Analysis

The Orofacial Examination Process and Analysis

Sarada Mauck

Iowa State University

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Orofacial Examination Analysis

Abstract

The Orofacial Examination is an important assessment in the overall assessment of

speech and language disorders. The Orofacial Examination looks at the structures

involved with speech production (i.e. lips, teeth, tongue, hard palate, velum, neck) to

identify any structural deformities and anomalies. Any deformities in the structures that

are used for speech and articulation show different issues in speech problems. It is

important for the clinician to be able to know the process of the examination step-by-step

and the reasoning behind why they are examining such structures to be able to provide a

thorough assessment and know the underlying problems associated with each step of the

examination.

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Orofacial Examination Analysis

The Orofacial Examination Process and Analysis

The Orofacial Examination goes in depth on examining the structures that

contribute to sound and articulation production. To have a better idea of the process and

steps taken for this examination, two videos were observed. The first video was titled,

Oral-Motor Exam 001 and the second video was titled, Oral Mechanism Exam for

Speech Language Pathology. Both of the videos went through the steps to perform an

Orofacial Examination, however, the first video more thoroughly went through the steps

while the second video went through a quick overview of the exam with a couple added

steps. These videos will both be analyzed and looked at though the steps, but because of

the more thorough nature of the first video (Oral-Motor Exam 001), it will be primarily

looked at.

The first step in the examination is introducing who you are and the procedures

that will take place during the examination. It is important to start with this simple step so

the client knows who you are and can bring up any questions or concerns regarding the

examination before it is conducted. The next introductory part of the exam is explaining

what the exam is. It is important to tell the client the structures that will be looked at so

they know what is being look at during the examination. The clinician should

communicate that the neck, teeth, and the visible inside area of the mouth are the primary

structures that will be looked at (Oral Motor Exam 001). It is important for the

clinician to mention the proper posture during this exam to the client- this includes sitting

upright and keeping their back straight. This way it is easier for the clinician to be able to

examine structures and the client to have open airways during the examination.

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Orofacial Examination Analysis

A step that was left out of the first video but was mentioned in the second video

was to sanitize the area and have the clinician wash their hands before performing the

exam. It is important to make sure that area is sanitary before the examination begins to

avoid any germs spreading and potential sickness being spread. The first procedure to ask

the client to perform is for them to hold their breath for six seconds. The purpose of

having the client do this is to see and hear for any audible distress or air that may be

escaping through the lips or the nose. After the client hold their breath for six seconds, it

is important to evaluate the structures of the face, such as: the nose, chin, lips, and bone

structure. If there is any asymmetry in the face, this could be an implication of fetal

alcohol syndrome, which should be further diagnosed (Oral-Peripheral Examination). It

is also important to note any drooping of the sides of the face or tilted movement of the

lips. If there is any drooping or abnormalities in structure, this could be a sign of facial

muscle paralysis and the client should be further diagnosed by another professional

(Shipley et. al) .

The next important step in the examination is to look at the structures on the

inside of the mouth. The clinician should use tongue depressor to hold down the tongue

to have a better view of the hard palate, soft palate, and the teeth can evaluate these

structures. It is also helpful for the clinician to use a flashlight to have a better view of the

structures inside of the mouth; it is also helpful to move the tongue side-to-side to have a

better view of the teeth. When evaluating the inside of the mouth, any signs of a cleft

palate should be noted as well as any teeth occlusions or discoloration on the tongue,

palate, or pharynx. While looking at the inside structure of the mouth, the clinician

should next check the strength of the tongue. The tongue depressor is an essential part of

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Orofacial Examination Analysis

this portion. Using the tongue depressor, the clinician should press down on the tongue

and have the client push their tongue upwards towards the roof of their mouth. This same

mechanism should also be done on the sides of the tongue. It is important to note tongue

strength during the evaluation because if the tongue is not very strong, the client may be

unable to move it enough to be able to produce certain sounds accurately.

Following the inside structures of the mouth, the clinician should then next

evaluate the lips. The lips can be evaluated by having the client pucker their lips and then

spread the lips thin by smiling. It is good again to note any drooping of the lips during

this portion of the examination. Following the movement of the lips, the clinician should

check the intra-oral pressure by having the client seal their lips and fill their cheeks with

air. While the cheeks are puffed out and full of air, the clinician should check the intra-

oral pressure by pressing on the clients cheeks and check for any nasal emission and the

lip strength of the client. It is important to check the intra-oral pressure of the client to

make sure there are no signs of a cleft palate that could be causing a weak intra-oral

pressure and emitting the air out of the nose (Craniofacial Anomalies, Cleft Lip/Palate,

and Resonance Disorders). Poor intra-oral pressure could also be a sign of

velopharyngeal incompetence, a functional problem, or velopharyngeal insufficiency, a

structural problem (Shipley et. al).

The next portion is meant to look at the teeth and the jaw. The clinician uses the

tongue depressor in the teeth strength evaluation; the clinician puts the tongue depressor

between the clients teeth and pulls the tongue depressor out of the clients mouth. Any

weakness of the teeth could cause articulation problems with dental sounds in the client,

so it is important to note any weakness in the teeth. Next the clinician looks at the jaw

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Orofacial Examination Analysis

movement and strength. The client is instructed to move the jaw from side-to-side as well

as anteriorly and posteriorly to check that the jaw has a full range of movement. If the

jaw does not have a full range of movement, this could affect mastication, swallowing,

and certain articulations. It is also important to note during the jaw movements any jerky,

groping, slow, or asymmetrical movements as well as any grinding or pooping noises that

could cause for further evaluation (Oral-Facial Examination Form). As well as the range

of movement of the jaw, the strength of the jaw should also be noted. This can be done by

having the clinician push upwards on the jaw while the client pushes their jaw open,

forcing the clinicians hand downward. This should also be executed the same way in the

opposite direction in which the client pushes the clinicians hand up with their jaw. The

purpose of evaluating jaw strength is to see if the client has any possibility of a

neurological impairment such as aphasia, dysarthria, or both (Shipley et. al).

The clinician should continue the exam by examining the tongue function of the

client. This portion of the examination involves the client performing several different

movements of the tongue, all including:

1. Protruding the tongue straight out

2. Curling the tongue so it point backwards

3. Pushing the tongue up against the right and left cheeks

4. Running the tongue along the roof of the mouth

5. Placing the tongue against the alveolar ridge

6. Placing the tongue against the front bottom teeth

7. Using the tongue to lick their lips in a full circular motion

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Orofacial Examination Analysis

These steps are to examine if the tongue is able to have full movement in all directions.

Followed by checking the movement of the tongue, the clinician should then check the

movement of the back of the tongue. To do this, the clinician should use a tongue

depressor to hold down the front of the tongue. Once the tongue is held down, the

clinician should instruct the client to repeat the syllable gah repeatedly. By looking in

the mouth, the clinician should be able to see if there are any problems with the

interaction between the back of the tongue and the soft palate.

Diadochokinetic testing is the next portion of the test. Diadochokinetic testing is

used to see how accurately a client can rapidly repeat a series of sounds to examine how

well the client is able to make sounds with the different parts of the mouth, tongue and

soft palate (Diadochokinetic (DDK) Rate). In this testing, the client is given a syllable

and a set time to repeat that syllable as many times as they are able. The set time during

the first video assessment was ten seconds and focused on syllables that focused on lip,

tongue, and soft palate movement. These three syllables were pah, tah, and gah.

Once the client has finished repeating these syllables individually, the clinician should

then instruct the client to do the same with all three syllables at once, repeating the three-

syllable pah-tah-gah in the span of ten seconds. Any problems within this portion of the

test could be used to determine if the client has ataxia, dysarthria, aphasia, oropharyngeal

disorders, or childhood apraxia of speech (if the client is a child) (Shipley et. al).

The soft palate is the next portion of the examination. During this section of the

examination, the clinician checks to see if the client can efficiently move the soft palate.

This can be done by having the clinician hold down the clients tongue with the tongue

depressor followed by having the client repeat ah with a glottal stop (//) inserted to

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Orofacial Examination Analysis

make a syllabic sound. After this step, the clinician should check and make sure that the

gag reflex is working properly. To do this, the clinician needs to use the tongue depressor

and stick it far into the back of the mouth until the gag reflex is induced. The importance

of checking for the gag reflex is because the gag reflex is quite important in the

swallowing mechanism, so checking to make sure for a functioning gag reflex is

important in determining if the client may have a swallowing disorder (Mason, 2014).

Lastly, the clinician should check for oral sensitivity. The clinician can perform this task

by using the tongue depressor to touch either the right or left cheek and then having the

client indicate with their hand which side was touched. The clinician should do the same

with the sides of the tongue as well.

The laryngeal examination is the next section of the Orofacial Examination. The

laryngeal examination has the client prolong an open vowel for six seconds with the

mouth wide-open. This is to check the voice quality of the client to identify any

hoarseness, gurgling, or if anything sounds like it is stuck in the throat. Following the

laryngeal examination the clinician should examine the phonation time of the client. In

this section, the client holds out an open vowel until they run out of air. This is to see if

the client has any respiratory issues in speech production. Followed by the phonation

time, the clinician should then check the clients pitch by having the client move their

voice up and down in pitch. Finally, the clinician should have the client cough and clear

their throat to ensure that those mechanisms are working properly.

The final portion of the examination includes the dry swallow. A dry swallow

involves the client performing a dry swallow while the clinician places their hands on the

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Orofacial Examination Analysis

clients throat to endure that the swallowing process is working efficiently. The clinician

should place four fingers of their dominant hand on the clients throat like so:

Index finger placed on the base of the mandible

Middle finger on the hyoid for elevation

Fourth finger on the cartilage

Pinky finger placed on the bottom for support and stabilization

The finger placement is crucial so that the clinician can ensure that the client can

effectively perform a swallow and make sure there are no signs of swallowing

difficulties.

To wrap-up the exam, the clinician should ask the client if they have any

questions after the examination has been completed. It is important to know the details

discussed previously of every portion of the exam so that the clinician can deliver any

questions knowledgeably to the client. Following questions, the clinician should make

sure that everything has been completed that needed to be. The Orofacial Examination

has a lot of different parts and steps, so it is important that the clinician is certain tat they

all have been completed. To end the examination, the clinician should thank the client for

their time.

Between the two videos analyzed, there were some steps in the second video

(Oral Mechanism Exam for Speech Language Pathology) that had some additional

steps that were not included in the first. One being to make sure that the client signs a

consent form. This ensures that the client is willing to go through the examination

without any legal consequences. Another is to check the palatal ridges and arch. This step

is important because any abnormalities with the height or width of the palatal arch could

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Orofacial Examination Analysis

lead to difficulties with palatal-lingual sounds and consonant distortions (Shipley et. al).

Finally, the clinician should check other structures such as the uvula, tonsils, and the

frenum. It is important to note if the client has their tonsils removed or not and if the

uvula seems to deviate because that would have implications of neurological

involvement. The frenum is important to note as well because if the frenum is too short in

length, the client would not be as able reach the alveolar ridge and produce lingua-dental

and lingua-alveolar sounds.

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Conclusion

The Orofacial Examination plays a critical role in the assessment process in

speech and language pathology. By performing an Orofacial Examination, a speech and

language pathologist has better implications as to what the underlying problems and

processes within speech might be within clients. Knowing information about biological

functions and being able to identify any abnormalities is helpful for being able to

properly refer the client to a specialist while still having some information on what the

problem may be. It is also helpful in narrowing down any possibilities that could result in

articulation disorders. Overall, it is important that a speech-language pathologist knows

how to perform and Orofacial Examination appropriately and also be aware of the

underlying reasoning to the sections and portions of the examination.

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Orofacial Examination Analysis

References

Oral-Motor Exam 001. (2013). Retrieved October 13, 2016, from

https://www.youtube.com/watch?v=lSO5Mqi-3KM

"Oral Mechanism Exam for Speech Language Pathology." YouTube. YouTube, 2013.

Web. 13 Oct. 2016. Http://www.youtube.com/channel/UC0vhLNwb-

nQ7Jlronrxa2hw.

Craniofacial Anomalies, Cleft Lip/Palate, and Resonance Disorders. Retrieved October

13, 2016, from http://www.asha.org/slp/clinical/Cleft-Lip-and-Cleft-Palate/

Mason, E. (2014, December 1). What is our gag reflex for? And why doesn't food trigger

it but almost everything else does? Retrieved October 13, 2016, from

https://www.quora.com/What-is-our-gag-reflex-for-And-why-doesnt-food-

trigger-it-but-almost-everything-else-does

Oral-Facial Examination Form [A form to use in performing an Oral-Facial

Examination]. University of Washington, Seattle, Washington.

Oral-Peripheral Examination [Powerpoint presentation explaining the basics of an Oral-

Peripheral Examination]. http://firstyears.org/c4/u6/oral-perif-exam.pdf

Diadochokinetic (DDK) Rate. Retrieved October 13, 2016, from

http://www.healthline.com/health/diadochokinetic-rate#Overview1

Shipley, Kenneth G., and Julie G. McAfee. Assessment in Speech-language Pathology: A

Resource Manual. Clifton Park, NY: Delmar Cengage Learning, 2009. Print.

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