NMS Q&A Family Medicine

The Oral Cavity in Primary Care 1310. The answer is C. Six months is the age at which childrenshould be receiving fluoride. This would be in theform of a supplement if the household water is not fluoridatedcommercially, publicly or in well water at a concentrationof 6 ppm. Supplement should be either topicalor oral or both. The child should not receive fluoride supplementationif it is breastfeeding and in any event notuntil the age of 6 months. Overdose can cause hypocalcemia,convulsions, tetany and cardiac dysrhythmias.11. The answer is D. Bacteria that cause dental caries (i.e.,mutans streptococci in the great majority) can be transferredamong members of a household, including frommother to newborn child. Children should be taken to thedentist by the age of 1 year. Teething is not a cause of fever ininfants. Bottle propping is unacceptable according to dentalopinion, for many reasons: First, because of the temptationto overfeed improper foods; second, there may eventually bemechanical effects on the dentition. The typical yellow tobrown to black discoloration is not the first appearance ofcaries. They are preceded by white spots or lines.12. The answer is E. Rubeola or “hard measles,” althoughclassically producing the buccal Koplik spot, does notcause glossitis. All the other listed conditions may be associatedwith glossitis.13. The answer is B. Beta-hemolytic streptococcus is virtuallythe only bacterial cause of bacterial pharyngitis.Streptococcal pharyngitis causes increasingly severe symptomsthroughout the day, whereas viral pharyngitis, as theharbinger of a viral upper respiratory infection, is worst inthe morning upon awakening. Although there is no singlereliable symptom or sign of streptococcal infection in thethroat, the combination of the chronicity and progressionof symptoms in this case, along with tenderness of theanterior cervical nodes and the cellulitic appearance of thethroat, point to such an infection. S . pneumoniae , the mostcommon cause of bacterial pneumonia, is not an oralpathogen, neither are Staphylococci (except in unusualcircumstances), M . catarrhalis , or H . influenzae .14. The answer is D. Dentigerous cysts. The third molarsare commonly only partially erupted in the adult. For thisreason, they are the foci of frequent abscesses that are due,of course, to the beta-hemolytic S . pyogenes . Further, whenthird molars or wisdom teeth remain totally unerupted,they may form dentigerous cysts (expansions of the originalcocoon of the molar roots); these may grow slowlyover time, taking on the characteristics of benign tumors,dislodging other teeth, and eroding the maxillary or mandibulararch. Malocclusion is not a significant occurrencein this condition. There are no cosmetic implications withunerupted third molars. Chewing is seldom a problemexcept in the partially erupted molar that has abscessformation.15. The answer is B. Infectious mononucleosis and streptococcalpharyngitis each may cause petechiae over the hardpalate, though the question regards a nonbacterial causeonly. Furthermore, adenopathy due to Bets strep is virtuallyalways tender whereas that due to infectious mono is virtuallynever tender. In children, herpangina (not mentionedamong the choices) causes palatal petechiae and occursmostly in preschool-age children, generally up to 4 years ofage. It may occur, however, as late in childhood as 16 years.In the present case, the existence of impressive lymphadenopathywithout tenderness is typical of mononucleosis.16. The answer is A. Periodontitis progresses to gingivitis,which, if untreated and severe, leads to acute necrotizinggingivitis or trench mouth. Periodontal abscessconsists of a focal lesion under pressure, which is quitepainful. Dentigerous cysts are not visible on oral examination.Molar impaction is the primary lesion from whichdentigerous cysts form, nearly always involving a thirdmolar that has not erupted and that impinges on surroundingstructures, particularly after cyst formation (seethe discussion of Question 13).17. The answer is D. Ludwig angina is cellulitis of thesubmandibular space by extension from the sublingualarea. It usually results from an infection of a dental site,such as that from an infected extraction site, root canaltherapy or abscessed third molar. Scrofula is tuberculousinvolvement of cervical nodes and, as such, consists of obviousadenopathy. Coronary insufficiency may cause anginalpains that radiate into the neck, but nearly always thisoccurs unilaterally and is not associated with local findings.Mucosal epidermolysis occurs on the mucosa, not theskin.ReferencesDouglass JM , Douglass AB , Silk HI . A practical guide to infantoral health . Am Fam Phys 2004; 70 ( 11 ): 2113 – 2119 .M.D. Anderson, University of Texas. www.mdanderson.org/patient-and-cancer-informationTryon AF , Streckfus CF . Problems of the oral cavity . In: RudyDR , Kurowski K , eds. Family Medicine: House Officer Series .Baltimore : Williams & Wilkins ; 1997 : 27 – 42 .US Preventive Services Task Force . Prevention of dental caries inpreschool children: recommendations and rationale . Am FamPhys 2004 ; 70 ( 8 ): 1529 – 1532 .Ward, Daniel, DDS, Clinical Associate Professor, The Ohio StateUniversity: Personal communication.