Oral Peripheral Examination

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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