Clin Oral Invest (1998) 2: 3–10
REVIEW
Reinhilde Jacobs · Charbel Bou Serhal
Daniel van Steenberghe
Oral stereognosis: a review of the literature
Received: 19 September 1997 / Accepted: 2 February 1998
Abstract Stereognosis is the ability to recognise and dis-
criminate forms. Oral stereognostic ability has been stud-
ied in different reports. The experimental design of the test
is of primary importance as both the method used and the
material applied may influence the results dramatically.
The form, size and surface characteristics of the test piece,
the presentation order, subject-related factors and the
method of scoring all have their effect on the results. With
regard to subject-related factors, ageing has a negative in-
fluence on stereognostic ability; gender is considered of
no importance. Another influencing factor is dental status.
A healthy natural dentition offers a very good oral stereog-
nostic ability. Edentulous subjects usually show a de-
creased oral stereognostic ability, depending on the reha-
bilitation form. A number of questions have been ad-
dressed, especially with regard to the perception itself. Re-
ceptors mainly involved in oral stereognostic ability are
located in various oral structures and form perception re-
sults from an association of more than one group of recep-
tors. The following review tries to deal with these ques-
tions and attempts to provide clear guidelines for further
research on oral stereognosis.
Key words Stereognosis · Dental status · Oral sensory
function · Periodontal mechanoreceptors
Introduction
Oral tactile information is conveyed through the trigemi-
nal nerve. Neurophysiological investigations of the trigem-
inal system in man are extremely scarce. Indeed, it is dif-
ficult to isolate peripheral bundles except, perhaps, for the
mandibular nerve. Needle recordings of the latter have
R. Jacobs (½) · C. Bou Serhal · D. van Steenberghe 1
Laboratory of Oral Physiology, Department of Periodontology,
Faculty of Medicine, Catholic University of Leuven,
Kapucijnenvoer 7, B-3000 Leuven, Belgium
Fax +32-16332484; e-mail: reinhilde.jacobs@med.kuleuven.ac.be
1
Holder of the P-I. Brånemark Chair in Osseointegration
© Springer-Verlag 1998
been rarely performed because these are painful. There-
fore, psychophysical approaches have been used, which
imply that subjects are questioned about their perception
of the stimulus applied and eventually about how they
sense it. Psychophysical tests have been developed to as-
sess the tactile function of the hand and fingers in partic-
ular. When these psychophysical methods are carried out
in a standardised way, the results seem to match the neu-
rophysiological receptor function [34].
One should make a distinction between proprioceptive
and exteroceptive receptors responding to mechanical
stimuli (mechanoreceptors). Proprioceptors [muscles spin-
dles, tempero-mandibular joint (TMJ) receptors] provide
information about the relative positions and movements of
the limbs. They are activated by stimuli from inside the
body. Exteroceptors, located in the periodontal ligament,
alveolar mucosa, gingiva and jaw bone, inform the central
nervous system of external loading. Mucosal mechanore-
ceptors serve in a variety of functional capacities includ-
ing sensation, composite sensory experiences (e.g. oral ki-
naesthesia and oral stereognosis), reflex initiation and
modulation of patterned motor behaviour. In addition,
mechanoreceptors in the periodontal ligament are primar-
ily responsible for the tactile function of teeth [14, 33]. The
latter receptors can also contribute to the coordination of
jaw muscles during biting or chewing.
The oral stereognostic ability test has a special interest
when comparing patients with different dental status.
Changes in oral sensation occur after the loss of natural
teeth and edentulous patients show difficulties, most of the
time, in adaptation to their new dentures. Many previous
studies used the stereognostic ability test to evaluate such
problems but also to evaluate differences in oral sensation
when changes in the oral cavity take place.
Methodological factors
Stereognostic ability is defined as one’s ability to recog-
nise and discriminate forms presented as a stimulus [6].
4
Table 1 Test piece characteristics in different studies

Reference Form Size Material

Thickness Length
(mm) (mm)

Berry and Mahood [1] 6 12 Acrylic resin

Shelton et al. [30] ? ? Plastic

Litvak et al. [22] 5 ? Metal alloy

Landt and Fransson [20] 1 ≤10 Acrylic resin

Lundqvist [23]

Van Aken et al. [35] 1 10–12 Plastic

Garrett et al. [9] 5 – Raw carrot

Müller et al. [28] 1.5–4 9 Acrylic resin

Jacobs et al. [15] 4 ≤10 Acrylic resin

Stereognosis is a more complex process than the simple
detection of tactile stimuli and involves different compo-
nents. Manual stereognosis is used in neurology, neuropsy-
chology and hand therapy to evaluate the functional per-
formance of the hand [5, 17]. Oral stereognosis can be ap-
plied as a measure of oral functioning. This test can be used
especially to test oral dysfunction or to evaluate the effect
of therapy.
Berry and Mahood [1] introduced the oral stereognosis
test and tried to develop a standardised test procedure (e.g.
shape, size, number, material). After this pioneering work,
oral stereognostic ability, also denoted as oral form recog-
nition, received further attention in the literature [10, 20,
24, 26, 27, 30, 36] and has been performed in different
ways with a different outcomes. An appropriate psycho-
physical methodology has often been neglected. Further-
more, a variety of materials, forms and sizes has been ap-
plied (Table 1). Oral stereognostic ability has been inves-
tigated in relation to other oral functions to measure im-
pairments due to the presence of general or local pathol-
ogy (e.g. speech pathology, blindness, deafness, cleft lip
and palate, temporary sensory ablations).
Regardless of the tests used, one must keep in mind that
many variables contribute to the subjective nature of psy-
chophysical sensory testing. Some variables are controlla-
ble, others are more difficult to deal with. The influencing
factors are found in the different components of the experi-
mental set-up (Table 2).
Environment
Background noise is distracting to the patient and the ex-
aminer. A test administered in a noisy environment is not
reliable. To minimise the effect of noise, all testing should
be done in a quiet, comfortable room and with stable illu-
mination. The examiner must be alert for sounds made by
a testing instrument before or during the application of a
stimulus. These sounds may cue the patient to a change in
stimulus. Such extraneous noises, and other sources of
noise, must be carefully eliminated during the psychophys-
ical experiment [7].
Examiner
Inter-examiner variability is a critical parameter in general
psychophysical testing. There is no doubt that a multitude
 5
Table 2 Observations from previous studies (NT natural teeth, FD full denture, FPi fixed prosthesis on implants, ODi overdenture on im-
plants)

Reference Dental Number Age Number Number Test conditions Results

status of (years) of of (% correct)
subjects pieces tests

Berry and Mahood [1] NT 15 15–50 10 1 Free manipulation 52.3

15 51–71 Free manipulation, age effect 39.6
FD 12 52–85 Successful denture 36.5
12 40–84 Unsuccessful denture 63.5
Siirilä and Laine [31] NT 20 20–25 10 1 Free manipulation 82.5
Litvak et al. [22] NT 21 20–31 10 2 Using teeth 69.5
Not using teeth 62.9
Wax covering teeth 55.0
NT 21 50–72 Using teeth 55.5
Not using teeth 50.5
Wax covering teeth 42.1
FD 48 50–75 No teeth 37.4
Maxillary denture only 40.0
Mandibular denture only 40.3
Both dentures (teeth not used) 42.3
Both dentures (teeth used) 44.9
Williams and La Pointe [36] NT 15 20–33 10 1 Free manipulation 70.0
Landt and Fransson [20] NT 20 21–26 12 3 Free manipulation 86.4
NT 20 60–70 3 Free manipulation 59.5
Landt [19] 30 Oral: with teeth 90
NT 10 17–18 20 30 Oral: without teeth 79
Van Aken et al. [35] FD 86 31–79 10 1 Dentures removed 57
Lundqvist [23] FD 19 41–66 12 3 (2) FD –
FPi 3 (2) FPi (immediately after placement) –
3 (2) FPi (3–6 months after rehabilitation) –
Garrett et al. [9] NT 71 48–85 10 2 Free manipulation 68.5
FD 64 48–85 1 With dentures 68.5
1 Without dentures 66.0
Müller et al. [28] FD 54 39–87 12 3 Free manipulation 70.5
Jacobs et al. [15] ODi 20 46–76 10 1 Test piece with toothpick to allow 52
FPi 20 40–74 placement of the piece between 56
NT 20 39–71 antagonistic teeth 75

of examiners leads to a lack of standardisation. In oral ster-
eognosis, most deviations occur when recording the iden-
tification time. In spite of a training programme in stereog-
nostic tasks, inter-examiner agreement remains weak [21].
One examiner may be faster than another when giving the
test pieces or even when recording the results. To solve this
problem and to assure the reproducibility of the data, ob-
servations must be carried out by only one examiner. Fur-
thermore, instructions to the patient before each test should
be standardised. Finally, the examiner’s and the subject’s
level of concentration should be taken into account.
Pieces
The form of a test piece not only has a great influence on
the quality of the responses but also on the time needed for
a given test. Forms should be of familiar patterns on which
there is universal agreement among people [27]. The items
should sample a wide variety of characteristics such as
straight lines, angles, concave and convex curves and eas-
ily perceived ratios of length and width [1]. Two equally
important factors are the intelligibility (ease of recogni-
tion) and confusability (degree of confusion with regard to
form similarity) of every individual form. Indeed, an ideal
form for testing form perception should have both a mod-
erate intelligibility and confusability value. The difficulty
in identifying a piece can vary widely between pieces and
tests. Of course, an increase in difficulty also implies more
time is required for correct or incorrect identification [18].
As to the shape, pieces with rounded corners are pre-
ferred to sharp corners [1] because they are more comfort-
able during manipulation. When manipulating pieces made
out of a strange material, it may be perceived as harmful,
provoking an impaired appreciation (e.g. metal instead of
acrylic resin).
It is recommended that different forms and sizes are
used, with a thickness of about 4 mm and a length of max-
imally 10 mm (Fig. 1). Furthermore, a toothpick should be
inserted in each test piece to allow a standardised place-
6
Fig. 1 Set of test pieces made in acrylic resin, consisting of five dif-
ferent forms and two different sizes for stereognostic ability testing
Fig. 2 Manipulation of a test piece in an oral stereognostic ability
test by using the hand to hold a toothpick. The toothpick is inserted
in the test piece to allow standardised placement between antagonis-
tic teeth and to avoid lip or tongue contact
ment of the test piece between two antagonistic teeth. This
may help to avoid lip as well as tongue contact and to im-
prove easy handling (Fig. 2). To facilitate the response pro-
cess, a chart can be presented in front of the subjects illus-
trating all test pieces in their normal and proportionally en-
larged size.
Scoring
Different procedures are followed for recording stereog-
nostic ability. In general, three types are reported, a three-
point scale, average identification of errors or average
identification time.
Three-point scale
This consists of classifying responses as one of three kinds,
correct, incorrect and half-correct. A response is consid-
ered correct if the subject identifies a given piece as pre-
cisely the one presented. In contrast, an incorrect response
is scored when the subject puts forward an object without
any similarity with the piece presented. In between these
two poles, an answer is considered as partially correct when
an object resembling the shape of the proposed piece is
chosen. The correct, partially correct and wrong responses
receive the respective scores of 2, 1 and 0 [31]. A slightly
different point scale consists of counting every correct an-
swer as 1, 2 for a partially correct response and 3 for wrong
identifications [35].
Average identification of errors
The examiner records the responses as correct or incorrect.
The evaluation is done by calculating the average or the
percentage of correct or incorrect responses [18–20, 22,
28, 36].
Average identification time
The examiner notes down the time required for identify-
ing a test piece, no matter whether it is right or wrong.
An important factor is not only the time consumed for
every piece but also for the whole identification process
[18, 19].
Patient
Patient-related variables may be of psychological or phys-
ical orders. Psychological factors include patient attitude,
level of concentration and, possibly, anxiety level. Each
patient brings his own perceptions to sensory tests; some
are more motivated than others for the test; some are sug-
gestible and may imagine a stimulus when there is none;
others admit a sensation only if they are absolutely posi-
tive it was felt.
Other patient-related factors are of physical origin, age,
gender, dental status and dexterity.
Age
In general, motor changes occur with age inducing, among
others, impairment of balance and unsteadiness of hand
motion. In addition, deterioration of most sensory modal-
ities in the distal extremities appears to occur almost inev-
itably with advanced age in humans [25]. Neurophysiolog-
ically, it is observed that the conduction velocity of the
nerve impulse in sensory and motor fibres decreases with
age [25]. A slight decline occurs after the age of 80 years
with regard to oral sensory function; the ability to differ-
entiate tactile and vibratory stimuli on the lip decreases,
the two-point discrimination deteriorates on the upper lip,
on the cheeks and on the lower lip, but not on the tongue
or the palate [3].

Older (60–70 years) subjects need over 80% more time
than younger (21–26 years) ones to identify test pieces
[20]. Identification errors are about three times more fre-
quent among older than among younger individuals. In
younger subjects, there is also a higher learning effect,
which is expressed by the reduction in time and errors
between the first and the third trial. Time is reduced by
22% in younger but only 5% in older subjects, and errors
by 54% and 16% for younger and the older subjects, re-
spectively [20]. A similar deterioration with age is also
noted for oral motor ability [20]. Other authors also re-
ported a decline with age [1, 19, 26, 28, 36].
When investigating the influence of age, one needs to
compare younger and older subjects with a healthy natu-
ral dentition. Conversely, when studying the influence of
dental status, the influence of age should be minimised.
Age- and gender-matched groups should be adopted or sta-
tistical age correction performed. The latter solution might
be needed because it is often difficult to select for compar-
ison a group of edentulous patients (usually being older)
and a group of subjects of the same age with a healthy nat-
ural dentition.
Gender
Few authors consider this factor important. Gender, indeed,
does not show any significant influence on stereognostic
ability [31]. Gender also does not affect lingual vibrotac-
tile function. The tactile sensory systems of men and
women operate similarly at both threshold and suprathres-
hold levels of stimulation [8]. However, females seem to
have a greater ability to discern subtle changes in lip, cheek
and chin position than males [4].
Dental status
A change in the oral cavity by means of partial or complete
loss of dentition certainly creates certain changes in oral
function. To evaluate the influence of dental status on oral
stereognostic ability, a number of cross-sectional studies
have been carried out (Table 2). In such studies, patients
with a full natural dentition are most often used as a con-
trol [1, 22]. Other cross-sectional studies only consider one
type of dental status.
When comparing teeth with full dentures, a far better
stereognostic ability is noted for natural teeth when freely
manipulating the test pieces [22]. However, significant
differences were no longer noted after the age of 60 years,
which may be due to a decrease in sensory abilities in gen-
eral [25].
Essential in dentate subjects seems the role of periodon-
tal neural receptors and of the tongue. After bilateral man-
dibular block, stereognostic ability decreases by about 20%
[24].
When removing the denture(s) in complete denture
wearers, a considerable reduction in stereognostic ability
is noted [22]. Furthermore, edentulous subjects who expe-
7
rienced a lot of problems after inserting their new denture
and those who show the lowest level of satisfaction dem-
onstrate higher levels of oral perception than those sub-
jects having few or no problems. Müller et al. [28] could
not detect a clear relationship between satisfaction and ad-
aptation to full denture and oral stereognosis.
Lundqvist [23] was the first to investigate longitudi-
nally stereognostic ability before and after rehabilitation
with oral implants. Both the identification time and the er-
ror score decreased significantly after rehabilitation with
implant-supported fixed prostheses, offering a better ster-
eognosis than full dentures. Jacobs et al. [15] compared
different prosthetic superstructures and noted no signifi-
cantly different stereognostic ability with implant-sup-
ported fixed or removable prostheses, even when eliminat-
ing the involvement of tongue and lip receptors.
When selecting only subjects with full dentures, one
may compare the stereognostic ability for different condi-
tions (e.g. adaptation to dentures) [9, 28, 35]. The best way
to investigate the influence of dental status is to consider
a patient group which will change its dental status and to
observe patients longitudinally before and after treatment.
Unfortunately, only one study applied this longitudinal de-
sign [23].
Dexterity
Although there is some relationship between masticatory
performance and hand dexterity [12], this is not the case
for stereognosis [27].
Oral versus manual stereognosis
In manual stereognosis, identification times are generally
shorter and identification errors lower than in oral ster-
eognosis. The correlation between identification errors
and identification times is moderate in oral and absent in
manual tests. In general, there is no clear relationship
between manual and oral stereognosis [19]. An oral ster-
eognostic ability test cannot be regarded as a measure of
stereognostic ability in general. A learning effect is obvi-
ous for most test pieces regarding identification time and
for about half of the test pieces regarding identification
errors.
Oral motor ability
An oral stereognostic test is frequently performed in con-
junction with an oral motor ability test in order to corre-
late the outcome of both tests [1, 31]. The reason is prob-
ably the similarity between both tests with regard to the
use of pieces in the mouth, one to identify (oral stereog-
nostic ability) and the other to fit two pieces complemen-
tary in form together (oral motor ability). Combining these
tests provides an expression of the oral sensorimotor func-
tion of an individual [23].
8
It should be mentioned that there is also a clear rela-
tionship between stereognostic ability and interdental
weight discrimination [36]. Subjects who are able to de-
tect very small differences in weight interdentally also per-
form very well when recognising forms in the mouth.
Masticatory performance
There is no relationship between stereognostic ability and
masticatory performance, either in dentate persons or in
denture wearers [9]. On the other hand, when comparing
stereognostic ability among denture wearers, significantly
higher scores were noted in subjects with high masticatory
performance [9].
Speech
A test for oral stereognosis may help the speech patholo-
gist in the treatment of an individual patient. Knowledge
of kinaesthetic feedback in speech behaviour could indeed
contribute to a better understanding of speech production
and perception [2, 30]. Stutterers and speakers with artic-
ulation problems have an impaired stereognostic ability in
comparison to normal speakers [27, 32], requiring more
time for the test than normal speakers.
Other factors
Hemiplegic subjects make approximately three times as
many errors as normal subjects in oral stereognosis tests.
Other pathological conditions in the perioral area have no
direct influence on stereognostic ability [29, 32]. Cleft lip
and palate is not accompanied by a sensory deficit of the
oral area. There is also no overall sensory impairment fol-
lowing tissue manipulation in cleft lip and palate surgery
[24]. The stereognostic ability of patients with burning
mouth syndrome is not significantly different from normal
subjects [11]. Cerebrally palsied speakers have an impaired
stereognostic ability [27]. A surgical reduction of the
tongue in cases of macroglossia has a minor influence on
the subject’s performance in the test for oral stereognosis
[13].
Receptors involved in oral stereognosis
To assess stereognostic ability, test pieces are inserted in
the oral cavity and in most experimental set-ups free ma-
nipulation of the test pieces is allowed. The latter implies
activation of a large number of receptor groups (periodon-
tal, mucosal, muscular, articular). Since the tip of the
tongue is one of the most densely innervated areas of the
human body, it plays an important role in stereognosis of
objects inserted in the mouth [31]. Oral stereognosis tests
give different results according to the location of the test
pieces; between the tongue and the hard palate, between
the tongue and the teeth or between the tongue and the lips.
During normal test conditions, the anatomical areas in-
volved are lingual – palatal and lingual – dental manipula-
tions. With unilateral anaesthesia, subjects continue to ro-
tate the objects on the anterior two-thirds and tip of the
tongue. With bilateral anaesthesia, manipulations are not
only lingual – palatal and lingual – dental, but also lingual –
labial [24]. When investigating the outcome of the oral ster-
eognostic ability test with or without using teeth, confu-
sion between test pieces rises from 10 to 21% and the mean
identification time increases from 17 to 26 s [19]. From
these findings, one may assume that a major role is played
by three groups of receptors, the tongue mucosa, the
palate and, to a lesser extent, by the teeth with their perio-
dontal ligament.
The role of the TMJ receptors is less clear since most
of the studies mentioned the role of different intra-oral re-
ceptors. In fact, in studies on tactile function, an interoc-
clusal thickness of 5 mm and more seems able to activate
receptors in the TMJ and the jaw muscles [14]. In stereog-
nostic ability tests, pieces are mostly manipulated inside
the mouth and seldom kept between two antagonistic teeth,
which frequently excludes the need for a mouth opening
of 5 mm or even more. When excluding other receptors,
osseous mechanoreceptors come into play but not to a large
extent [16].
General discussion
The majority of methods designed for neurophysiological
and psychophysical sensory testing are unable to identify
the specific receptor groups involved in the mechanisms
of oral sensation or perception. It is obvious that differ-
ences and even some contradictions are noted when com-
paring the results of numerous studies. This is partially
caused by the multiplicity of receptor types involved in
many oral structures due to free manipulation of the pieces,
but also by the lack of direct recording from sensory affer-
ents, which is not common in psychophysical testing.
Stereognostic ability testing is indeed not designed to
detect specific receptor groups, rather, it reflects an over-
all sensory ability. A good result in a stereognosis test
should indicate that the subject receives full and accurate
information about what is going on in the mouth. Even if
some manipulation is allowed to identify the test piece, the
identification itself is a sensory rather than a motor accom-
plishment [1]. It has been established that this kind of sen-
sory testing is an indicator of functional sensibility, includ-
ing the synthesis of numerous sensory inputs in higher
brain centres [31]. Some authors tried to limit the involve-
ment of certain structures in order to localise other recep-
tor groups involved, e.g. by covering the palate or the upper
or lower teeth with wax [22], or by simply not allowing the
teeth to be used for manipulation [18, 19].
Oral stereognosis, or recognition of forms, necessitates
perfect reception of the impulses set up by the stimuli. The

sensations produced are synthesised in the cortex and com-
pared with previous sensory memories. Presumably, oral
stereognosis involves a certain amount of motor activity,
manipulating the test piece within the mouth and feeling
its surface with lips, tongue, teeth and palate. The infor-
mation obtained must be associated with sensory memo-
ries derived from visual and tactile (finger-tip) experience
when available. It can thus be stated that abilities other than
the purely oral sensory function influence the identifica-
tion of test pieces in the mouth.
Two important parameters for evaluating stereognostic
ability are the time consumed for identification of the
pieces and the accuracy of the responses. With regard to
the latter, large variations are often noticed among studies,
and this is due to a lack of similarity in experimental set-
ups. Many factors play a role, mainly the multiplicity in
the form and size of the test pieces (different degrees of
difficulty). In addition, the time also varies and that can be
related to experimental variables as well as to the patient
himself.
Conclusions
The mechanism of oral stereognosis is determined by a va-
riety of neural receptors belonging to many oral structures
and by the functioning of higher coordination centres.
Some structures (oral mucosa, tongue) are more involved
than others (bone). The experimental design and the use of
a standardised method are of primary importance and
should be taken into account in future investigations, since
both the method used and the material applied may influ-
ence the results dramatically. Guidelines are necessary to
reach this purpose:
1. A standardised set should be used with regard to the
form, size and surface characteristics of the test piece.
2. The use of one order of presentation helps for accurately
comparing the results. This is not advised when repeating
the test on the same subject. In addition, one method of
scoring should be followed.
3. The insertion of a toothpick in each test piece allows a
standardised placement between two antagonistic teeth.
This may help to eliminate the involvement of lip and
tongue receptors and to improve easy handling.
On the other hand, subject-related factors should also be
considered:
1. Ageing has a negative influence on stereognostic abil-
ity. Gender is considered of no importance.
2. Dental status is usually dependent on the aim of the
study. Subjects with a healthy natural dentition or denture
wearers patients with oral implants can be tested.
The oral stereognostic ability test can be used to evaluate
patients after therapy (e.g. oral implants) and especially in
a longitudinal design.
Further studies are needed to more clearly define the
role of periodontal mechanoreceptors in oral stereognosis.
9
Continuous efforts should be made to use an appropriate
experimental design to allow comparisons. Prospective
studies are needed to evaluate how changes in dental status
may alter oral stereognostic ability.
Acknowledgements This research was supported by the Fund for
Scientific Research, Flanders, Belgium (FWO-Flanders-Belgium).
R. Jacobs is a postdoctoral research fellow of the FWO.
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