2022 PREP Self-Assessment

840 Pages·2022·10.861 MB·english

by  Susan Guralnick

PREP ® Self-Assessment PREPSA 2022

American Academy of Pediatrics 1
PREP ® Self-Assessment PREPSA 2022

Question 1
3-year-old boy is seen for a health supervision visit. His mother notes that some of his teeth have
developed areas that are whiter than others, similar to those shown in Item Q1 and asks what the
cause is. He does not complain of any pain. He eats a healthy diet, drinking 24 ounces of whole
cow milk per day in addition to tap water. His mother strictly limits his sugar intake. He does not
engage in non-nutritive sucking. He has not yet seen a dentist and he brushes his teeth twice a
week with a pea-sized amount of toothpaste. He takes no other medications or supplements. His
medical history is unremarkable as is his family history with no history of dental problems. On
physical examination, his vital signs and growth parameters are within normal limits. His
examination findings are normal, with the exception of the dental findings.

Item Q1

Of the following, the MOST likely cause of the dental findings for the boy in the vignette is
A. dental erosion
B. early childhood caries
C. fluorosis stains
D. inherited enamel defect

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Correct Answer: B
The most likely cause of the findings for the boy in the vignette is early childhood caries (ECC),
given his poor oral hygiene (brushing only 2 times per week) and the pattern of discoloration that
follows the gum line. Dental erosion usually results from increased exposure to acid for which
this child has no risk factors. Fluorosis stains (Item C1A) are usually more scattered in location,
inherited enamel defects appear as white discoloration, but will affect all teeth and are relatively
rare.

Item C1A & Item C1F: Fluorosis categorized as (A) very mild, (B) mild, (C) moderate, and (D) severe.
Reprinted with permission from Lewis CW. Fluoride and dental caries prevention in children. Pediatr
Rev. 2014;35(1):6

Even before their child's first tooth erupts. Pediatricians should advise caregivers on appropriate
oral care. Caregivers should set a good example for their child by limiting their intake or
cariogenic substances such as sweets and tobacco, brushing their own teeth twice daily with
fluoridated toothpaste. Flossing once daily, and seeing a dentist semiannually. They should clean
their child is gums with a clean cloth, especially after any feeding, with naps or at night.
Pediatricians should advise caregivers against bottle-propping and putting the infant to bed with
a bottle. These activities promote prolonged exposure to carbohydrates which can lead to caries
development.

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PREP ® Self-Assessment PREPSA 2022

Tooth eruption usually occurs by 12 months of age. Delayed eruption has many causes, including
those listed Item C1B. After the first tooth erupts. Children should have their teeth brushed with
fluoridated toothpaste, using a rice grain-sized amount for children younger than 3 years and a
pea-sized amount for children aged 3 to 6 years (Item C1C). Fluoride varnish should be applied
semiannually. Either by the general pediatrician or by a pediatric dentist. Other age-based oral
health care guidelines are listed in Item C1D and the Bright Futures Oral Health Pocket
Guide.

Item C1B: Causes of Delayed eruption
• Prematurity
• Low birthweight
• Genetic abnormalities like amelogenesis imperfecta and regional odontodysplasia
• Nutritional deficiency
• Down’s syndrome
• Hypopituitarism

Item C1C: A rice-grain-size amount of 1,100-ppm fluoride toothpaste contains 0.055 mg of fluoride. A
pea-size amount of 1,100-ppm fluoride toothpaste contains 0.27 mg of fluoride.
Reprinted with permission from Lewis CW. Fluoride and dental caries prevention in children. Pediatr
Rev. 2014;35(1):10. (photographs courtesy of Katherine Lewis, PhD).

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PREP ® Self-Assessment PREPSA 2022

Item C1D: Oral health care guidelines
Minimize exposure to natural or refined sugars
in the infant’s mouth.
• Avoid frequent exposure to foods that can lead to dental caries.
• Hold the infant while feeding. Never prop a bottle (ie, use pillows or any other object to hold a
bottle in the infant’s mouth).
• Do not allow the infant to fall asleep with a bottle that contains milk, formula, juice, or other
sweetened liquid.
• Avoid dipping pacifiers in any sweetened liquid, sugars, or syrups
• For infants and children younger than 3 years, brush the teeth with a small smear (ie, no larger
than a grain of rice) of fluoride toothpaste twice a day (after breakfast and before bed). The child
should not spit out the toothpaste or rinse with water. The small amount of toothpaste that
remains in his mouth helps prevent dental caries.

Prevent the transmission of caries-causing bacteria from adult to infant:
– Practice good oral hygiene and seek oral health care.
– Do not share utensils, cups, spoons, or toothbrushes with the infant.
– Do not put the child’s pacifiers in their own mouths. Clean pacifiers with mild soap
– and water.
– Consult with an oral health professional about the use of xylitol gum or lozenges (if the adult’s
oral health is a concern). This gum may have a positive effect on oral health by decreasing the
bacterial load in an adult’s mouth

Fluoride supplementation (Item C1E) should be considered if the primary water source is
inadequately fluoridated. Fluorosis occurs when children are exposed to excess fluoride,
especially before 8 years of age. After this age, the risk for fluorosis is extremely low, because
all teeth, except the third molars, have completely mineralized. The vast majority or fluorosis in
the United States is either very mild or mild (Item C1F. panels A and B). Moderate and severe
fluorosis (Item G1F, panels C and D) and systemic fluorosis are rare in the United States but
more common in countries where natural fluoride levels in the water are higher.

Item C1E: Fluoride supplementation

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Inadequate oral hygiene contributes to caries development, which can initially be asymptomatic
and appear as white discoloration. Without treatment, the caries may become browner and go
deeper into the tooth, causing pain, and if severe, lead to an abscess or facial cellulitis. Early
childhood caries refers to caries in children younger than 6 years and usually affects the upper
incisors, because these teeth are less protected by saliva. The lower teeth are generally spared
because they are better protected by sativa; canines ore also spared because they have smoother
surfaces that do not allow bacteria to accumulate. Caries in older children is more likely to be in
between teeth or affect the molars, which have more grooves.

Inadequate oral hygiene also contributes to periodontal disease. Allowing for plaque build-up
and gingival hyperplasia that easily bleeds and cap be painful. Periodontal hyperplasia can also
be infiltrative as in acute monocytic leukemia, idiopathic, or caused by medications (e.g.,
phenytoin. cyclosporine, o calcium channel blockers). In the latter case, the hyperplasia is not as
painful as prone to bleeding. Chronic gingivitis may progress to gingival recession leading to
loss of bone around the tooth, which may cause pain, sensitivity, and tooth loss. Gingivitis from
poor hygiene usually presents in adolescence or adulthood. Children With-severe gingivitis or
unexplained gingival hypertrophy should be evaluated for other systemic conditions listed in
Item C1G.

Item C1G gingival hypertrophy
– Hereditary: Hereditary gingival fibromatosis
– Storage diseases: GM1 gangliosidosis, I-cell disease
– Drug-induced: phenytoin, nifedipine, and cyclosporin A
– Infiltrative: Leukemia, particularly myelogenous leukemia,

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Enamel defects not from caries appear was a rough, white, yellow, or brown discoloration on the
crown of the tooth. Defects can lead to sensitivity, tooth fracture, and caries. Risk factors include
trauma to the primary teeth. Nutritional deficiencies during pregnancy or childhood (especially
vitamins A, C, or D; calcium; or phosphate), and prematurity. Item C1H shows an example of a
congenital enamel defect.

Dental erosion is usually a result of extrinsic acids, such as orange juice, or intrinsic acids, such
as stomach acid Acidic drinks or bulimia usually affect anterior teeth. Acidic solid foods or
gastroesophageal reflux disease usually affect the molars. Item C1I demonstrates erosion on the
lingual aspect of the central incisors in a child with gastroesophageal reflux disease.

Item C1I gastroesophageal reflux disease lingual dental erosion

Children with special health care needs are at higher risk for oral health problems. For instance,
those with severe reflux may experience dental erosion. Children who require polypharmacy
may experience side effects such as dry mouth, which to caries formation. They may also be
uncooperative with daily oral hygiene practices. A dental home that specializes in children with
special needs is therefore crucial for these children.

A brief patient education video from the AAP (healthy children.org) regarding oral health in
children can be found at https://youtu.be/Av26wxBjmdq.

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Oral Health Risk Assessment Tool

PREP Pearls
• Early childhood caries present in children younger than 6 years as white discoloration
along the gum line of upper incisors and may progress if untreated.
• Good oral hygiene can prevent most dental and periodontal disease, begins before the
first tooth erupts, and includes limiting the intake of cariogenic substances, appropriate
fluoride usage, flossing, and having a dental home.
• Children with special health care needs are especially prone to develop dental and
periodontal disease.

ABP Content Specifications
• Recognize the causes of delayed dental eruption
• Recognize the various clinical findings associated with dental and periodontal disease

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Suggested Readings
• American Academy of Pediatrics, Oral health. https://www.aap.org/en-us/advocacy-and-
policy/aap-health-initiatives/Oral-Health/Paqes/Oral-Health.aspx.
• Dental problems. American Academy of Pediatrics Textbook of Pediatric Care. 2nd ed. 1948-
1952.
• Council on Children with Disabilities, and Section on Oral Health Oral health care for
children with developmental disabilities. Pediatrics, 2013;131(3):614-619. Reaffirmed June
2018. doi: 10.1542/peds.2012-3650.
• Section on Oral Health, Maintaining and improving the oral health of young children.
Pediatrics 2014; 134(6):1224-1229. Reaffirmed January 2019. Doi 10.1542/peds.2014-2984
• Slayton RL. Oral health. In: Mclnerny TK, Adam HM, Campbell DE. DeWitt TG, Foy JM.
Kamat DM, eds. American Academy of Pediatrics Textbook of Pediatric Care. 2nd ed. Itasca.
IL: American Academy of Pediatrics, 2017:281-291. Pediatric care online

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Question 2
A 7-year-old girl is brought to the emergency department for severe muscle cramping in her
hands and feet. The cramping has increased in frequency over the past several days and worsens
with physical activity. She has no significant past medical history. She has a temperature of
37°C, heart rate of 96 beats/min, blood pressure of 102/66 mm Hg, respiratory rate of 14
breaths/min, and oxygen saturation of 98% on room air. Her height and weight are at the 40th
percentile. While the blood pressure cuff is inflated, her hand and wrist muscles maintain
sustained contraction. When her facial nerve is lapped, the corner of her mouth twitches. The
remainder of her physical examination findings are unremarkable. An electrocardiogram shows a
prolonged QTc interval.

Laboratory results are shown:

Laboratory Test Result
Calcium 6.6 mg/dL (1.7 mmol/L)
Albumin 4.2 g/dL (42 g/L)
Phosphorus 8 mg/dL (2.6 mmol/L)
Sodium 140 mEq/L (140 mmol/L)
Potassium 4 mEq/L (4 mmol/L)
Blood urea nitrogen 17 mg/dL (6.1 mmol/L)
Creatinine 0.5 mg/dL (44.2 µmol/L)
Glucose 86 mg/dL (4.8 mmol/L)

Of the following, the MOST likely etiology of the girl's hypocalcemia is
A. Albright hereditary osteodystrophy
B. hypoparathyroidism
C. renal tubular acidosis
D. vitamin D deficiency

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