Staining of the teeth may be intrinsic or extrinsic. Intrinsic stains may be due to tetracycline use prior to 8 years (yellow, gray, or brown stain). Iron preparation (black stain) is an example of extrinsic stain. Extrinsic stains can be polished off; intrinsic stains cannot (see Table 17-15, Abnormalities of the Mouth and Teeth, p. 772).

Look for abnormalities of the position of the teeth. These include malocclusion, maxillary protrusion (overbite), and mandibular protrusion (underbite). You can demonstrate the latter two by asking the child to bite down hard and part the lips. Observe the true bite. In normal children, the lower teeth are contained within the arch formed by the upper teeth.

Carefully inspect the tongue, including the underside. Most children will happily stick their tongue out at you, move it from side to side, and demonstrate its color (the blue tongue below is from eating candy!)

Note the size, position, symmetry, and appearance of the tonsils. The peak growth of tonsillar tissue is between 8 and 16 years (see figure on p. 656). The size of the tonsils varies considerably in children and is often categorized on a scale of 1+ to 4+, with 1+ being easy visibility of the gap between the tonsils, and 4+ being tonsils that touch in the midline with the mouth wide open. The tonsils in children often appear more obstructive than they really are.

Tonsils in children usually have deep crypts on their surfaces, which often have white concretions or food particles protruding from their depths. This does not indicate disease.

Malocclusion and misalignment of teeth is often due to excessive thumb sucking and is reversible if the habit is arrested by 6 or 7 years. Malocclusion can also be a hereditary condition, or due to premature loss of primary teeth.

Common abnormalities include coated tongue in viral infections, congenital geographic tongue, and strawberry tongue found in scarlet fever.

Streptococcal pharyngitis typically produces a strawberry tongue, white exudates on the tonsils, beefy-red uvula, and palatal petechiae.

A peritonsillar abscess is suggested by asymmetric enlargement of the tonsils and lateral displacement of the uvula.

Look for clues of a submucosal cleft palate, such as notching of the posterior margin of the hard palate or a bifid uvula.. Because the mucosa is intact, the underlying defect is easily missed.

There is one condition—acute epiglottitis—now thankfully rare in the United States due to immunization against Hemophilus influenzae type B, which is a contraindication to examination of the throat because of potential gagging and laryngeal obstruction.

Note the quality of the child's voice. Certain abnormalities can change the pitch and quality.

Voice Changes—Clues to Underlying Abnormalities

Voice Change

Possible Abnormality

Hypernasal speech

Submucosal cleft palate

Nasal voice plus snoring

Adenoidal hypertrophy

Hoarse voice plus cough

Viral infection (croup)

"Rocks in mouth"


You may note an abnormal breath odor, which may help lead to a diagnosis.

You may note an abnormal breath odor, which may help lead to a diagnosis.

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