- speech-~echanism Assessment tion, a small dental mirror and gauze pads may be necessary. Before putting the gloves on, clean the table with disinfectant and wash your hands thoroughly with antibacterial soap. YOU will need to select an appropriate form to rate your client's on the speech-mechanism assessment (see Figure 4.1 ). Always explain to the client what you will be doing and why you are doing it during the evaluation. INITIAL IMPRESSIONS The speech-mechanism assessment should begin as soon as you see the client. Generally speaking, the assessment moves from broad to specific. First, observe whether there is anything unusual, for example, on the face or asymmetry of features. This is also when you will want to be aware of the client's breathing. It should be noted if the client has a mouth-open posture and adequate breath support for connected speech. Again, strong observational skills will allow you to notice asymmetry of oral movement during connected speech and control of saliva when speaking. Be aware of the client's overall voice quality because that could be suggestive of possible speech-mechanism problems such as nasality due to inadequate velopharyngeal closure. Engaging the client in a brief conversation or in play will also allow you to have an idea of overall speech patterns. Some of your most valuable diagnostic information can be noted in functional situations. These initial impressions will guide you in the diagnostic process, directing you to the areas that may require additional attention when completing the speechmechanism assessment. Remember, too, that accurate results, in any testing situation, are best obtained when you and the client are actively engaged. So, try to maintain a light, conversational tone throughout, in order to help the client relax and give the most valid performance. c-, EXTERIOR FACE )In fragile X syndrome in adult males, fvl cnaulplc, CllL LacL CC1luJ Lu lull5 411U narrow. Low set, rotated ears are characteristic of Noonan syndrome. Facial asymmetry is common in velocardiofacial syndrome. It is important, then, to examine the external face for any indication that some syndrome might be present. When there is indication of syndromic features, referral to a geneticist is appropriate. The first step in the formal assessment is the evaluation of the facial symmetry. It is important to watch for any tremors, spasms, or tics, especially in the adult population. Is there any abnormal tension or lack of normal muscle tone in the oral musculature? Is there any drooping on either side of the face? Next, observe if the client is able to maintain good lip approximation. Is there any scarring or evidence of a cleft? A mask-like appearance with minimal facial expression could be suggestive of Parkinson's disease. Observing overall facial. expression, such as symmetrical smiles and frowns, suggests normal facial enervation, whereas slight drooping on one side of the lips or face could suggest nerve damage. Table 4.1 provides information about using some information from the examination of the external face to assess function of cranial nerves V, VII, X, and

~uckendorf and Gordon XII. Look at spacing, shape, and symmetry of the eyes and ears. If there are any facial abnormalities, determine through medical history whether they are acquired (secondary to injury or disease) or congenital (cleft palate or related to a syndrome). Perceptual skills, including tactile sensitivity, give you clues to symmetry, tactile acuity, and localization abilities of the individual. An inability to discriminate two points separated by an inch or more may provide clues as to the patient's diagnosis and areas that you may need to be aware of in treatment. Assess sensation on the upper and lower lips and cheeks by having your client close his or her eyes and see if he or she can identify a soft touch (Q-tip) and hard touch (tongue depressor). Assess two-point discrimination (with two tongue blades separated about an inch) and sensitivity to the temperature contrasts of hot (spoon warmed in hot water) and cold (spoon cooled in cold water). LIPS The lips are very important for nutrition, facial expression, and speech production. Lip approximation is an integral part of many speech sounds, and lip closure is a part of the swallowing process. If a person is unable to easily approximate his or her lips or the movement appears effortful, then there may be an impact on speech production. The initial observation allows you to determine if the lips are symmetrical in a resting posture and during speech. Many times, observing a natural smile is a good way to assess lip retraction. Scars on the upper lip could suggest a repaired cleft lip or an accident. This is a good time to assess overall facial tone. To assess lip seal, ask clients to fill their cheeks with air and hold that air for 10-1 5 seconds. Did you notice any air leaking from the lips? Are your client's lips sealed at rest? Can the client lateralize, protrude, and retract lips bilaterally and sustain a rapid series of bilabial sounds? Can the client rapidly open and close the lips several times a second? Push against the protruded lips with a tongue blade or gloved finger. Is there good resistance? Ask the client to grimace or pucker rapidly several times in a second. Count how many repetitions the client can make in 10 seconds. Do you notice groping behaviors during these tasks or does the client repeat these lip movements easily and quickly? Because lip protrusion (lip rounding) is especially important in the production of vowels, it is a good idea to count the number of times the client can pucker and then smile or open and close his or her mouth. Then ask the client to repeat "0-e" as many times as possible and count the number of complete repetitions of "0-e." During the production of bilabial sounds (m,p,b), you can observe whether the person uses both lips or makes compensatory movements to achieve closure. You can also observe speed of alternating movements and look for any drooping of the client's mouth. In the Dworkin-Culatta Oral Mechanism Examination and Treatment System (Dworkin &- Culatta, 1996), the client is asked to perform many of these activities as well as repeat "puppy" as rapidly as possible for 5 seconds. Again, these observations help you determine whether there are functional impediments that occur in both speech and nonspeech situations or whether articulation errors are confined to speech contexts alone.

ipe,ch-h.techankm Assessment 99 Jaw movement, including opening and closing, as well as freedom of movement and stability of the temporo-mandibular joint (TMJ), is important to speech production and chewing. If freedom of movement is impaired, rate of movement is slowed, or the client has habituated a clenched-jaw posture that may affect speech production and needs to be addressed during the evaluation. The jaw opens and closes many times during speech, and limited movement secondary to injury or neurological disorder can have a significant effect on speechintelligibility. Does the client have adequate movement of the jaw or present with more of a clenched-jaw posture, like a ventriloquist? This is also a good time to listen for any TMJ noise, such as grinding or popping sounds during w i d e - m ~ ~opening. th Some clients may not be able to open their mouths fully because of TMJ problems and a referral to a dentist may be in order. Jaw lateralizati~nis important for chewing and provides information about cranial nerve function, so you want to observe whether the client can move the jaw from side Breathing irregularities can lead to decreased respiratory support for speech, so it is important to assess whether there are any obstructions in the nasal cavity that could affect breath intake. You can ask the client to move his or her head back and assess.the nasal area for any abnormalities such as a deviated septum or obstruction of the nasal cavity. This is especially important if you have observed that rhe client is a mouth breather. Also note any nasal air emission during speech. That is best observed by either placing a small dental mirror under the client's nose and asking him or her to repeat words with no nasal phonemes, or placing a small strip of paper under his or her nose and observing movement of the paper during those same words. When a client uses words with no nasal phonemes, there should be no clouding of the mirror or movement of the paper. Many clients are unable to breathe comfortably through their nose because of allergies or swollen adenoids. This should be noted both during the examination and in the case history, and clients should be referred for medical management of this issue. Nighttime snohng and chronically red upper gums are additional clues to this condition. If the client is unable to breathe comfortably through the nose, then the adoption of an unhealthy mouth-open breathing posture becomes more likely. INTRAORAL EXAMINATION Looking inside the client's mouth gives you a view of the structures and functions the articulators. This is necessary in order to determine if there is any obstruc; n or inadequacy that might contribute to a speech problem. In preparation f,or intraoral examination, you will need to glove and review the characteristics of tissue indicating structural abnormalities in Table 4.2. Also, you will want to be familiar with terminology such as tremors, tics, and spasms to describe any invol-