Every dental examination already includes a look at the back of the mouth. With one small change to how that look is performed and recorded, it becomes a standardised airway assessment. The Mallampati score takes around 30 seconds, needs nothing more than good light, and gives dentists a consistent way to describe how crowded a patient’s oropharynx is.
The British Academy of Dental Sleep Medicine (BADSM) teaches the Mallampati classification as part of a wider airway screen alongside questionnaires such as STOP-Bang. This article explains where the score comes from, how to grade it reliably in the dental chair, what a Mallampati score of 3 or 4 means, and where its limits lie.
What Is the Mallampati Score?
The Mallampati score was introduced in 1985 by the anaesthetist Seshagiri Mallampati as a bedside predictor of difficult tracheal intubation. The original study proposed that when the base of the tongue is large relative to the oropharynx, it obscures the faucial pillars, soft palate and uvula, and that the same disproportion makes the larynx harder to expose. Mallampati described three classes. In 1987, Samsoon and Young added a fourth class, in which the soft palate cannot be seen at all, and this four-class version is the one most clinicians use today.
The logic that makes the Mallampati score useful in anaesthesia also makes it useful in sleep medicine. A tongue that crowds the oropharynx while the patient is awake and upright is likely to crowd it further when the patient is asleep, lying down and the pharyngeal muscles relax.
The Mallampati Classification Explained
The Mallampati classification grades what can be seen of the oropharyngeal structures with the mouth fully open:
| Class | Structures visible | What it suggests |
| Class I | Soft palate, fauces, uvula and both tonsillar pillars | Ample oropharyngeal space |
| Class II | Soft palate, fauces and uvula | Mild crowding |
| Class III | Soft palate and base of the uvula only | Moderate crowding |
| Class IV | Hard palate only; soft palate not visible | Marked crowding |
The score describes the relationship between the tongue and the oropharynx rather than the size of either structure alone. A patient with a normal-sized tongue can still grade as class III or IV if the mandible is retrusive or the dental arch is narrow.
Original, Modified and Friedman: Which Version Are You Using?
Several versions of the test are in circulation, and mixing them up is one of the main reasons scores vary between clinicians.
Original Mallampati. Three classes, assessed with the patient seated, head in a neutral position, mouth open as wide as possible and tongue protruded maximally, with the examiner at eye level.
Modified Mallampati score. Usually refers to the four-class version introduced by Samsoon and Young, performed with the tongue protruded and without phonation. Confusingly, some sleep medicine literature uses “modified Mallampati” to describe the same four classes assessed with the tongue left inside the mouth.
Friedman tongue position. Widely used in sleep medicine, this version assesses the tongue relaxed in the floor of the mouth rather than protruded. Because protrusion draws the tongue forward, the tongue-in position is thought to reflect more closely how the tongue sits during sleep. A 2013 meta-analysis evaluated the diagnostic value of both the Friedman tongue position and the Mallampati classification for OSA.
Whichever version a practice adopts, the important thing is to use the same one every time and to record which one was used.
How to Grade the Mallampati Score in the Dental Chair
- Sit the patient upright with the head in a neutral position, rather than reclined in the chair.
- Position yourself directly in front of the patient at eye level.
- Ask the patient to open as wide as comfortably possible and protrude the tongue fully (or rest it in the floor of the mouth if you are using the tongue-in version).
- Ask the patient not to say “ahh”. Phonation lifts the soft palate and can make the airway look less crowded than it is.
- Do not use a mirror or tongue depressor; the score depends on the unassisted view.
- Grade what you see against the four classes, repeat once to confirm, and record both the class and the version used.
Reclining the chair is the most common error in dental settings: gravity moves the tongue backwards and changes the view. Once the team is familiar with the technique, grading takes around 30 seconds and fits easily into a routine examination.
What a Mallampati Score of 3 or 4 Means
A higher Mallampati class indicates that the tongue fills more of the oropharynx, which in sleep medicine terms is a marker of reduced airway space. The clearest evidence comes from a prospective study of 137 adults evaluated for possible OSA, in which each one-point increase in Mallampati score raised the odds of OSA roughly 2.5-fold and was associated with an increase of around five events per hour in the apnoea–hypopnoea index. Those associations held after accounting for more than 30 other variables reflecting anatomy, body habitus, symptoms and medical history.
Mallampati score 3
Only the soft palate and the base of the uvula are visible. On its own this is a moderate risk marker. Combined with snoring, daytime sleepiness, hypertension or a neck circumference of 40 cm or more, it justifies a STOP-Bang questionnaire.
Mallampati score 4
Only the hard palate is visible. This represents marked crowding and should prompt structured sleep screening, particularly as it frequently coexists with other anatomical signs such as a scalloped tongue, retrognathia or enlarged tonsils.
The Limits of the Mallampati Score
The Mallampati score is a screening sign, not a diagnostic test, and the evidence is not uniformly positive. A study in sleep clinic patients concluded that Mallampati class was not useful in their clinical assessment. One likely explanation is that patients already referred to a sleep clinic have a high probability of OSA, so an additional anatomical sign adds relatively little. Agreement between examiners can also be modest, especially when different versions of the test are used.
These limitations point to how the score should be used in dentistry: as one element of a combined assessment. A high Mallampati class does not mean a patient has sleep apnoea, and a low class does not rule it out. Non-anatomical traits such as airway collapsibility, arousal threshold and ventilatory control also drive OSA, as discussed in BADSM’s article on OSA phenotypes and endotypes.
The Mallampati Score in Anaesthesia and Sedation
Many dentists first meet the Mallampati score in the context of anaesthesia or conscious sedation, where it forms part of airway assessment before a procedure. The same finding carries information in both settings. A patient with a high Mallampati class may be harder to manage if airway support is needed during sedation, and is also more likely to have a crowded airway during natural sleep. Recording the score once serves both purposes, and a patient whose airway is flagged before sedation is a patient worth asking about snoring and sleep.
Combining the Mallampati Score With Other Chairside Findings
The Mallampati score is most useful when read with the rest of the examination. A practical airway screen in general dental practice combines:
- A validated questionnaire such as STOP-Bang.
- The Mallampati class, and the version of the test used.
- Tongue scalloping and tongue size relative to the arch.
- Palatal shape, tonsil size and mandibular position.
- Tooth wear consistent with bruxism, and patient-reported symptoms such as dry mouth on waking or morning headaches.
Where the combined picture suggests elevated risk, the next step is referral to the patient’s GP or a sleep service for diagnostic testing, in line with NICE guideline NG202. If OSA is later diagnosed and a mandibular advancement device is considered, the recorded Mallampati class becomes part of the baseline airway assessment.
Frequently Asked Questions
What is the Mallampati score?
The Mallampati score is a four-class grading of how much of the soft palate, uvula and tonsillar pillars can be seen with the mouth open and the tongue protruded. It was developed to predict difficult intubation and is also used as an anatomical risk marker for obstructive sleep apnoea.
What is the difference between the Mallampati and modified Mallampati score?
The original Mallampati score had three classes. The modified Mallampati score usually refers to the four-class version that added class IV, in which only the hard palate is visible. Some sleep medicine sources also use the term for an assessment with the tongue kept inside the mouth, so it is important to record which method was used.
What does a Mallampati score of 3 mean?
A Mallampati score of 3 means only the soft palate and base of the uvula are visible. It indicates moderate oropharyngeal crowding and, alongside other risk factors, is a reason to screen for sleep apnoea.
What does a Mallampati score of 4 mean?
A Mallampati score of 4 means only the hard palate is visible. It indicates marked crowding and should prompt structured sleep screening and, where risk is confirmed, referral.
Can a dentist diagnose sleep apnoea using the Mallampati score?
No. The Mallampati score identifies anatomical risk. Diagnosis of obstructive sleep apnoea requires a sleep study arranged through a GP or sleep service.
Should the patient say “ahh” during Mallampati assessment?
No. Phonation raises the soft palate and can make the airway appear less crowded, leading to an underestimate of the true Mallampati class.
Want to build a reliable airway assessment into every examination? Join BADSM as a member and explore our dental sleep medicine courses.
Dr Aditi Desai is the President and Founder of the British Academy of Dental Sleep Medicine, with over 20 years of experience in oral appliance therapy and a co-author of the Standards of Care for Mandibular Advancement Devices.
