ORAL PERIPHERAL EXAMINATION
Name ______Date ______Examiner ______
LIPS: Habitual Posture: Closed Open Mobility: Press Purse Retracts
JAW MOBILITY: Sufficient Insufficient Excessive
TONGUE: Size: Appropriate Too large Too small Frenum: Normal Short Close to tip
Habitual Posture: Retracted Protruded
TONSILS/ADENOIDS: Removed? Yes No If yes, date ______Size: Normal Abnormal
LIPS-JAW-TONGUE DIFFERENTIATION:
Response to verbal instructions or single imitative example: Score: 3=with ease; 2=with difficulty; 1=unable to do
___Stick tongue out of mouth (no accompanying head movements or touching lips/teeth)
___Elevate tongue tip (tip lifts independently, without overflow movements of head or jaw)
___Do lateral wags (tongue moves independently through space, without head/jaw movements)
___Retract tongue back to pharynx (back of tongue moves back; tip doesn’t curl back)
___Acquire lingual-palatal suction (firm palatal contact; makes a symmetrical tongue-pop)
___Acquire taut, straight tongue (indicative of good lingual muscle tone and endurance)
Total score: ____Circle one: (15-18 within normal limits; 12-14 low normal; 12 and below, poor oral differentiation)
Comments: ______
DENTITION:
Dental Occlusion: Normal Appearance Abnormal Appearance If yes, complete below:
__Overjet __Underjet __Openbite __Crossbite __Edge to edge __Wears Orthodontics
PALATE: Hard Palate: Normal High Arch Cleft Soft Palate: Normal Cleft
Uvula: Normal Other: ______
SHALLOW: (overall) ___Normal swallowing pattern ___Abnormal swallowing pattern (If yes, see below)
___Exhibits tongue thrust ___Teeth are held apart ___Inefficient intra-oral suctioning
BREATHING: Mouth Breather? __Yes __No If yes, apparently due to: habit nasal obstruction
ORAL HABITS: Thumb sucking? __Yes __No Tongue sucking? __Yes __No
DIADOCHOKINESES: (See instructions for assessment of diadochokinetic rate.)
Puhpuhpuh (avg. = 3-5 ½) - Adequate Inadequate
Tuhtuhtuh (avg. = 3-5 ½) - Adequate Inadequate
Kuhkuhkuh (avg. = 3-5 ½) - Adequate Inadequate
Puhtuhkuh (avg. = 1-1 ¾) - Adequate Inadequate
TACTILE SESITIVITY: Firmly stroke face and neck with gloved hands or cloth, and oral areas with a tongue depressor, Toothette or Ora-Swab.
a. Face and Neck __Normal __Hyper __Hypo
b. Lips __Normal __Hyper __Hypo
c. Gums and Inside of Cheeks __Normal __Hyper __Hypo
d. Tongue Surface (front) __Normal __Hyper __Hypo
e. Tongue Surface (back) __Normal __Hyper __Hypo
f. Hard Palate __Normal __Hyper __Hypo
g. Soft Palate __Normal __Hyper __Hypo
h.
Tactile Acceptance: Weak 1 2 3 4 5 Defensive
Comments: ______
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