(#46) The Quick 5-Phase Oral Mech Exam

1.  While You are Talking to the Child

• Are the lips comfortably closed when the child is not talking? If not, are they parted? Just slightly parted, or are the lips apart because the jaw is lowered? Do they look like they would close if the jaw was elevated? Are they closed/parted consistently or inconsistently?
• Does the lower lip slide under the top, front teeth at rest? This would indicate a dental overjet.
• If his lips are apart, do you see the tongue? Is it down, or down and forward? If it’s down, the child is probably breathing through his mouth. If it’s down and forward, he’s probably blocking his oral airway and he’s breathing through his nose.
• If the lips are parted, why? Make a note to go back later and check to see if the child can achieve nasal airflow, or not. Try to track down why.

• The structure of the cranio-facial bone is the bony framework of the mouth. Making note of external characteristics will guide your investigation once you’re inside the mouth.
• A narrow face may indicate a narrow dental arch. A wide face may indicate an excessively wide dental arch. Both of these extremes may make tongue-palate resting and speech sound production effortful. Note the word “may;” some individuals are able to compensate, others aren’t.
• Note jaw symmetry. Does the lower jaw jut off to one side or forward?
• If the child produces “frontals” it’s not unusual to see a longer face with chronically parted lips. And, when lips are open, the tongue is down, probably at the horizontal midline. (Conversely, it is ideal for the tongue to rest on top so it can easily access speech sound stabilization and mobilizations.)

• The ideal profile is when the jaws are straight vertically and in proportion to one another.
• Keep in mind that wherever the jaw goes, so goes the tongue. If the jaw is either forward or retracted (in relation to the dental arch and palate) the tongue may have difficulty accessing and interacting for speech. There may be frontal productions or general lack of clarity due to lingual contact-imprecision with the alveolar ridge and palate.
• In other words, if the mandible is significantly protruded or retruded, the tongue may or may not be able to correctly interact (rest, stabilize and mobilize) with the roof of the mouth.

2.  While the Child is Talking to You

• Watch the child’s jaw as he speaks. Do you see excessive jaw movements either vertically or horizontally or, does the child try to speak with his jaw elevated?
• Do you frequently see the surface of a child’s tongue as he speaks? It is not normal to chronically see the surface of the tongue when speaking. Ideally the tongue interacts up within the dental arch, with the tongue-sides on the side teeth to one degree or another. A very visible tongue-surface may indicate a tongue that is operating on the horizontal plane (it moves anteriorly-posteriorly) rather than vertically.
• Determine the tongue’s primary movement plane. Does the whole tongue move horizontally? Or do you see front-tongue vertical movements? Consonant speech sounds are made with front- and back-tongue vertical movements. It means that he is able to successfully move the front part of his tongue.

• Vertically, the top front teeth overlap the bottom front teeth within the top third of the bottom teeth.
• Horizontally, it is normal for the top front teeth to be “out” from the bottom front teeth 1 to 3 mms.
• Also, children go through mixed dentition between the ages of 5 to 13 or so.

• Note the stage of dental development. Is he in the deciduous phase (all baby teeth), or has he moved into the mixed dentition phase? If he’s a middle- or high-school student he may have all of his adult teeth.
• Note the condition of his teeth. Is his occlusion good, or does he have a dental malocclusion, such as, an openbite (vertical space in front or on the sides), or an overbite (too much front-teeth overlap), or an overjet (horizontal protrusion), or underbite (Class III)? Look at quadrants of teeth, not just individual teeth to determine a malocclusion. Keep in mind that teeth don’t typically move “out of position” on their own. There’s usually a reason, e.g., thumb, finger, pacifier, tongue, etc.
• Compare what you learned from analyzing the jaw-to-jaw profile relationship. Are the characteristics you saw on the “outside” reflected on the “inside”? If there is a significant difference between the jaws (externally) and the teeth (internally), determine why. For example, if the external jaw-to-jaw profile looks straight, but inside, the lower teeth are tipped forward (as in an underbite), chances are the tongue has been chronically pushing against the lower, front teeth. This lets you know that the tongue chronically moves horizontally. In all probability, he has a frontal speech pattern. (Basically, connect the dots.)
• Is the child wearing orthodontic braces?

4.  Investigate Inside

• Determine if the size of his tongue is commensurate with the size of his mouth. (This is obviously subjective but is easily recognizable when there’s a big difference; the tongue fills the oral cavity.)
• When “at rest” is his tongue basically still or are there fasciculations? Meaning you see slight twitches and movements. Some people feel that this is a soft-sign of neurological issues; personally, I think the jury is still out. Observe over time, however, for consistency.
• Place a tongue depressor on the front-to-mid surface of his tongue to see if he accepts the sensory input. If he not, you’ll probably get a gag response. Look quickly at the pharynx to see if there are tonsils. If he is accepting of the tongue depressor, continue to the back and apply moderate pressure on the back of the tongue to get a view of his pharynx. Simultaneously ask him to say “ah.” Determine if he has tonsils or not and look at the size of his pharynx. Your goal is to determine if there is space for the base of the tongue to rest and function within the pharyngeal area. While you’re back there have him say “ah” again and make note of soft palate vertical movement.
• Next look underneath the tongue. Make a note of the lingual frenum, e.g. where it’s attached (mid-tongue or toward the tongue tip), and its vertical length. We’ll come back to the lingual frenum in Phase #5. The most effective way of analyzing the lingual frenum is through tongue-palate contact.
• A less common occurrence are restrictive labial frenums. If you noticed that he has a significant space between his front teeth (typically the top) it may be due to a short labial frenum. Directly check the frenum by lifting (or lowering) the lip with your tongue depressor to view the frenum.

5.  Observe and Interact with the Dental Arch and Palate

• First, eyeball the width of the upper dental arch, as well as the width and height of the hard palate. Without the benefit of tongue interaction, it’s subjective. Extremely narrow or extremely wide is obvious. Either of these may pose lingual stabilization difficulty (see Therapy Matters #7 on Tongue Bracing).
• Make note of the appearance of the alveolar ridge and the hard palate. A younger child will have a bumpy alveolar ridge and an older child or teen should have a smooth alveolar ridge. The more years the tongue has rested and interacted on top, the smoother the alveolar ridge. In addition, sometimes the alveolar ridge is “pointed.” This unusual shape makes it tough for tongue interaction.
• Are there appliances up within the dental arch and palatal vault? If there is a palatal expander, make note of the type and ask the child how long it’s been in (see Therapy Matters Blog #42). Is there a thumb/finger/tongue reminder appliance? These are usually positioned below the alveolar ridge and/or palate in an effort to “block” the offender.

• Ask the child to do a tongue pop. Does the tongue easily lift and fit up into the roof of the mouth? If so, all systems are go.
• Is his tongue able to elevate up to the top or does the anterior portion fold back in an effort to make palatal contact? If so, this is a red flag indicating that tongue-palatal positioning is not familiar. His tongue, therefore, probably rests and functions “down” at midline.
• If the tongue is unable to reach the top, it may be tethered by a restrictive lingual frenum. Check the tongue’s “reach-ability.”
• If the palatal distance is too great for the tongue (for whatever reason), ask the child to bite on a child-sized tongue depressor with his back teeth and do a tongue pop as best he can. The small tongue depressor keeps the jaw closed and centered and the tongue in close proximity to the roof of the mouth. Chances are, if the tongue is able to reach and fit, it will. If not, it won’t.