Article ear, nose, and throat

Oral Conditions
David M. Krol, MD,
Objectives After completing this article, readers should be able to:
MPH,* Martha Ann Keels,
DDS, PhD† 1. Describe the appropriate treatment of a ranula.
2. List the conditions that predispose to persistent or recurrent candidiasis of the oral
cavity in an infant younger than 6 months of age.
Author Disclosure 3. List the conditions that predispose to persistent or recurrent candidiasis of the oral
Drs Krol and Keels did cavity in children older than 6 months of age.
not disclose any 4. Distinguish clinically among hand, foot, and mouth disease, herpangina, acute herpetic
financial relationships gingivostomatitis, and aphthous ulceration.
relevant to this 5. Discuss the therapy for children who have a short lingual frenulum.
article.

Introduction
This review addresses a variety of oral conditions that clinicians likely encounter in their
practices, some more often than others. Recognition of normal and abnormal features of
a child’s mouth is an important part of the physical examination because oral health is an
integral part of a child’s overall health.

Oral Candidiasis
Candidiasis is the most common oral fungal infection of infants and children. Although
this infection can lead to serious complications when systemic, invasive, or manifested in
immunocompromised individuals, it is encountered more commonly by the primary care
pediatrician in a more benign presentation.

Causes and Epidemiology

A variety of species of the genus Candida can lead to oral disease in humans, including C
albicans, C glabrata, and C tropicalis. C albicans is the species associated most commonly
with oral candidiasis, accounting for 70% to 80% of the oral isolates. Candida is a
dimorphic fungus that can exist in both a yeast phase (blastospore) and a hyphal phase.
This ability to exist in two forms contributes to its ability to spread, survive, and cause
disease.
Even in the absence of disease, as many as 60% of healthy individuals may harbor
Candida in their oropharyngeal region, not to mention on the skin and in the intestinal
tract and vaginal area. Most commonly, infants acquire Candida during passage through
the vagina or postnatally. Oral candidiasis, commonly known as thrush, affects approxi-
mately 2% to 5% of otherwise healthy newborns.

Pathogenesis and Clinical Manifestation

Although Candida may be present in a host’s oral cavity, the fungus does not cause
pathologic change unless that host’s defense mechanism is compromised. Such a decrease
in host defense in infants may result from the immaturity of the immune response.
Decreased resistance to infection also may result from and be a sign of a compromised
immune system (eg, human immunovirus infection [HIV]) or other disease processes (eg,
diabetes) in older children. External systemic and local insults to the immune response also
may lead to oral candidiasis (eg, antineoplastic or immunosuppressive therapies, inhaled
corticosteroids), as can local insults to the natural ecology of the oral flora (eg, frequent

*Chair, Department of Pediatrics, University of Toledo, Health Sciences Campus, Toledo, Ohio.
†
Assistant Clinical Professor, Department of Pediatrics and Surgery, Duke University Medical Center, Durham, NC.

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ear, nose, and throat oral conditions

courses of antibiotics). Impaired salivary flow caused by responds well to treatment with a topical antifungal
disease or medication and poor oral hygiene also may agent such as nystatin suspension or clotrimazole troches
lead to candidal pathology. (lozenges). An appropriate regimen for neonates is
The symptoms of oral candidiasis can range from 100,000 U four times per day or 50,000 U to each side
none to a sore and painful mouth, a burning feeling on of the mouth four times per day. Older infants require
the mucous membranes and tongue, or dysphagia. In- 200,000 U four times per day or 100,000 U to each side
fants who cannot verbalize their symptoms may present of the mouth. Children and adolescents are treated best
having difficulty eating, a decrease in oral intake, or with 400,000 to 600,000 U four times per day, or if
refusal to eat due to the discomfort. using the troches, 200,000 to 400,000 U four times per
The most common presentation, pseudomembra- day. Treatment duration usually is 2 weeks, but medica-
nous candidiasis (thrush), involves white or whitish- tion should be continued 2 to 3 days beyond the resolu-
yellow plaques and erythema on the tongue, soft palate, tion of symptoms. Gentian violet has been used as a
and buccal mucosa. The plaques may be wiped off to treatment for oral candidiasis but is less effective than
reveal raw, erythematous, and sometimes bleeding mu- newer antifungal medications.
cosa underneath. The changes in the mucosal surface are Systemic antifungal medications may be required for
due to the superficial invasion of the mucosa by the patients who do not respond to topical treatment and
fungus and help the clinician separate infection from milk children who are immunocompromised. In these cases,
curd. The presence of concomitant diaper rash also may fluconazole (6 mg/kg po on day 1 as a loading dose,
aid in the diagnosis of an oral candidal infection. Less followed by 3 mg/kg po qd for 14 d; for adolescents,
frequently, clinicians may note angular cheilitis, a fissur- 200 mg po loading dose, followed by 100 mg po qd for
ing or red scaling at the corners of the mouth. 14 d), itraconazole (used as a “swish and spit” of
Another less common variation of oral candidal in- 100 mg/10 mL twice a day for 7 to 14 d), or ketocon-
fection is erythematous candidia-

Children
sis, sometimes referred to as
atrophic candidiasis. These ery-
thematous patches, seen most of-
ten on the palate and dorsum of
older than 6 months of age
the tongue, are associated primar- who present with persistent or unexplained,
ily with children who are taking frequent relapses of oral candidiasis
broad-spectrum antibiotics or cor-
ticosteroids or children who are warrant consideration of a systemic
HIV-positive. immunodeficiency. . . .
Diagnosis and Treatment
Oral candidiasis usually can be diagnosed clinically, al- azole (5 to 10 mg/kg po divided once or twice a day for
though it should be differentiated from other infections 5 to 7 d; for adolescents, 200 to 400 mg po qd for 5 to
and trauma. Other conditions in the differential diagno- 7 d) can be prescribed.
sis include the oral mucositis associated with chemother- It is important to remind parents that pacifiers, tooth-
apy, oral hairy leukoplakia, and burns of the oral mucosa. brushes, vitamin droppers, and other objects that may
Although oral candidiasis is the most common oral fun- have come in frequent contact with the infected child
gal infection of infants and children, rare oral fungal also may be harboring Candida and should be discarded
infections, especially in immunocompromised individu- and replaced. Oral candidiasis that persists or recurs soon
als, are possible and include aspergillosis, cryptococcosis, after treatment in children younger than age 6 months
histoplasmosis, blastomycosis, and mucormycosis. merits consideration of these possible external reservoirs
Candidiasis usually is a clinical diagnosis, but it also is of the fungus. Another cause of recurrent or persistent
possible to test for the yeast cells and pseudohyphae of C oral Candida infection is frequent or long-term antibi-
albicans by 10% to 20% potassium hydroxide or Gram otic use. Children older than 6 months of age who
stain examination under the microscope. This technique present with persistent or unexplained, frequent relapses
is especially useful when patients do not respond to of oral candidiasis warrant consideration of a systemic
treatment or for immunocompromised individuals. immunodeficiency in addition to the other causes men-
In infants and young children, oral candidiasis usually tioned.

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 ear, nose, and throat oral conditions

Recurrent or persistent oral candidiasis in breastfeed-

ing infants should raise the consideration of maternal
breast colonization as a cause. Mothers may complain of
unexplained nipple pain, burning, or itching or exhibit
erythematous, cracked areolae. In these cases, it is wise to
apply an antifungal agent to the maternal nipple while
treating the infant.

Ankyloglossia (Tongue-tie)
Definition
Ankyloglossia, commonly referred to as tongue-tie, is a
congenital anomaly characterized by an abnormally short
lingual frenulum leading to a variable degree of compro-
Figure 1. Thick, fibrous membrane binding the tongue to the
mised mobility of the tongue. Reference to ankyloglossia
mouth floor.
may be found as far back as the Bible: “. . . and the string
of his tongue was loosed, and he spake plain.” (Mark
7:35) touch the upper lip or protrude it beyond the lower lip.
The definition and the management of ankyloglossia A thickened frenulum also may result in a space or
are somewhat controversial. Definitions range from sub- diastasis between the lower incisors.
jective descriptions of tongue range of motion and frenu- Significant constriction can interfere with breastfeed-
lum prominence to more objective measures, such as the ing. This impairment may manifest as maternal com-
Hazelbaker Assessment Tool for Lingual Frenulum plaints of traumatized nipples, pain with feeding, and
Function. The Hazelbaker Tool takes into account five incomplete breast drainage. Infants may have difficulty
appearance and seven function items to calculate an latching onto the breast, prolonged feedings, and even
objective score of lingual frenulum function. Currently, poor weight gain. All of these effects may lead to early
the Hazelbaker Tool does not have sufficient validation weaning. Feeding difficulties are less pronounced in
to warrant widespread use. tongue-tied infants using artificial nipples.
It is important to note that although a short lingual
Epidemiology frenulum can affect speech articulation in later years, it
As might be expected in the absence of a standard does not cause speech delay. Older children may have
definition of ankyloglossia, the incidence of the anomaly difficulty licking their lips or playing wind instruments,
varies; it is uncommon, although not rare. In the litera- but it is extremely difficult to predict which affected
ture, the incidence of ankyloglossia varies from 0.02% to children will develop articulation or mechanical difficul-
4.8%. This variability also may be due to age-related ties. Once the child has upper posterior teeth (age 2 y), it
differences because some cases may resolve spontane- is important to observe if he or she is able to lateralize the
ously with age. When limiting the age range to the tongue to clean the buccal vestibules. Not being able to
neonatal period, the incidence ranges from 1.7% to 4.8%. self-cleanse the facial surfaces of these teeth can put the
A male predominance of the anomaly has been noted child at risk for caries and calculus accumulation.
in the literature (range, 1.7:1 to 2.6:1). Usually, anky-
loglossia is an isolated anatomic variation, although it has
been noted to occur with increased frequency in some
congenital syndromes (eg, Opitz syndrome).

Pathogenesis
The severity of ankyloglossia varies in degree from a thin
membrane that binds the tongue to a severe form
wherein a thick, fibrous membrane binds the tongue
closely to the floor of the mouth (Fig. 1). The tongue
may look heart-shaped, with a notch, due to the tether-
ing of the frenulum (Fig. 2). Children who have severe Figure 2. Heart-shaped tongue due to tethering by the frenu-
ankyloglossia may not be able to elevate the tongue to lum.

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ear, nose, and throat oral conditions

Treatment
Most children who have ankyloglossia are asymptomatic,
and the condition resolves in some spontaneously over
time. Thus, most affected children need no intervention
beyond reassurance. When there is concern that anky-
loglossia may be affecting breastfeeding, it is wise to refer
to a lactation consultant for evaluation. In more severe
cases, especially when there are obvious effects on breast-
feeding that do not respond to lactation consultant in-
tervention, or in older children who have problems in
speech articulation, a surgical procedure known as fre-
nectomy may be appropriate.
Frenectomy (frenotomy), or clipping of the frenulum,
is a relatively benign surgical procedure that often is
performed in early infancy with little or no anesthesia. Figure 3. Lower lip mucocele.
Outcomes are usually good, and there are few postoper-
ative complications. Numerous insurance companies A mucous cyst arising from the floor of the mouth is
consider the procedure medically necessary when new- known as a ranula, a name derived from the Latin word
born feeding difficulties or childhood articulation prob- rana, which means frog, because the lesion is suggestive
lems exist. It is important to remember, however, that of a frog’s belly. Ranulas also occur in the first and second
neonatal frenectomy is not indicated for every infant who decades of life and have no sex predilection.
has ankyloglossia.
Before deciding which infants might benefit from the Clinical Manifestation and Cause
procedure, clinicians should examine the oral cavity, Mucoceles are caused most often by lip biting or minor
assessing both anatomy and function. For infants who are injury to the lip, with the lower lip being the most
breastfeeding, it is important to discuss with the mother common site (Fig. 3). They appear well-circumscribed,
her experience of breastfeeding and to observe a feeding have smoothed surfaces, and are soft and bluish or trans-
to detect any problems (eg, latch). If the history, physical lucent. Mucoceles are usually painless and can range
examination, and feeding observation confirm significant from 1 mm to several centimeters in diameter. The cystic
problems with breastfeeding and the continuation of lesions are filled with mucin from the underlying dam-
breastfeeding is desired, a frenectomy is indicated and aged minor salivary duct.
should be performed by a professional experienced in the A ranula is caused by injury to the duct of the sublin-
procedure. This individual could be the pediatrician or a gual gland, submandibular salivary gland, or one of the
pediatric dentist, surgeon, or otolaryngologist. In an minor salivary glands in the floor of the mouth. A ranula
older child who has significant articulation problems appears as a soft, bluish swelling on one side of the floor
attributed to ankyloglossia, frenectomy referral is indi- of the mouth (Fig. 4). A plunging ranula develops when
cated. Because frenectomy in these cases is more likely to
require general anesthesia, referral should be made to an
experienced surgical professional.

Mucous Cysts in the Oral Cavity (Mucoceles,

Ranulas)
Definitions
The most common mucous cyst occurring in the oral
cavity is the mucocele, also called mucous extravasation
phenomenon. Mucoceles occur in the first and second
decades and have no sex predilection. The lesion arises
from mechanical trauma to the duct of one of the minor
salivary glands in the lips or cheeks. Although mucoceles
appear cystic, they are not true cysts because they are not
lined by epithelium. Figure 4. Ranula.

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 ear, nose, and throat oral conditions

the cyst herniates through the mylohyoid muscle to

involve the neck.

Treatment
Some mucoceles resolve when the patient bites (unroofs)
the cyst with his or her teeth. The cyst ruptures, and the
resulting lesion heals spontaneously. Children who have
not developed teeth may require surgical excision, as
might children who have developed keratinized mucoce-
les. A mucocele can enlarge, becoming unsightly and
more firm in consistency, from the child chewing or
sucking on the lesion. The enlargement and the fibrotic
nature can make self-rupture of the lesion unlikely and
can be an indication for excision. Removal of the muco- Figure 5. Herpetic gingivitis.
cele must include excision of the underlying damaged
minor salivary gland to avoid recurrence. Surgical exci-
sion of a mucocele can result in damage to another minor
salivary gland, and patients must be warned of this po- gingiva appears “fire engine red,” hemorrhagic, and
tential outcome. All excised tissue should be submitted edematous (Fig. 5).
for pathologic examination to confirm the diagnosis. HSV infection usually is diagnosed by clinical presen-
Ranulas are removed by surgical excision. Larger tation and history. Culture, polymerase chain reaction
ranulas may require marsupialization. To minimize re- (PCR) testing, or antigen testing can help differentiate
currence, removal of the associated gland is critical. HSV infection from other conditions. Whether the clini-
cian obtains a viral culture, PCR testing, or antigen
testing depends on the testing available at the hospital or
Ulcerative Lesions clinic, and testing becomes necessary only when the
Ulcers in the oral cavity, regardless of cause, present condition is not obvious clinically.
similarly, manifesting as areas of yellow, pseudomembra- HSV infection generally can be managed with sup-
nous slough with an erythematous border. Intraoral ul- portive care, including hydration and analgesia. Milk
cerations vary in size and location, but it is important to products are helpful in coating the ulcerations as well as
obtain a thorough history to differentiate viral from hydrating the child. The disease usually resolves sponta-
nonviral ulcerations. neously within 10 to 14 days without any scarring. If the
child is unable to take oral fluids, intravenous fluids are
Primary Herpetic Gingivostomatitis indicated. Some institutions elect to treat children with
This infection is caused primarily by herpes simplex virus acyclovir 200 mg administered five times a day, or the
(HSV) type 1, although some children, such as those equivalent, until all lesions have resolved.
who have been sexually abused, are infected by HSV type Parents should help the child avoid developing lesions
2. The clinical manifestation of infection by either type is in other areas by not touching the infected area and then
identical in the oral cavity. These lesions rarely are cul- touching other mucosal surfaces, such as the eyes or
tured to differentiate the HSV type. A history and phys- genitalia. After primary oral infection with HSV, the
ical examination should be used to determine if inocula- virus resides in the trigeminal ganglion and remains
tion was due to child abuse. latent until reactivated. Secondary infections with HSV
The peak incidence is around age 2 years. The disease typically occur on the lower lip following a stressful
typically presents 3 to 50 days after the exposure. Fre- event.
quently, the inoculation is from contact with an infected
family member who is shedding the virus, such as a Herpangina and Hand, Foot, and Mouth
parent who has a recurrent herpetic lesion on the lip. Disease
Two days prior to the outbreak of oral lesions, the child These infections are caused by the Coxsackie group
experiences a high fever, irritability, and malaise. Initially, A viruses and tend to occur primarily in epidemics during
several small vesicles develop on the gingiva that subse- the fall and winter months when children are clustered.
quently rupture and form large, painful ulcerations. The Both conditions have a prodromal phase of malaise, sore

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ear, nose, and throat oral conditions

Traumatic Ulceration
Ulcerations due to trauma are common in childhood
following injuries to the mouth. Children who have been
anesthetized for a dental procedure frequently chew the
insides of the lips or cheeks inadvertently and develop a
traumatic ulceration that appears as a yellow, pseudo-
membranous slough with an erythematous border. Ap-
plication of a topical over-the-counter anesthetic (eg,
teething gel) may help alleviate pain before mealtimes or
before toothbrushing. The administration of a systemic
analgesic such as ibuprofen may help manage the pain
until the lesion resolves.

Recurrent Aphthous Ulceration (RAU)

RAU is categorized into two types based on the size of
Figure 6. Riga-Fede ulceration. the ulceration. Minor aphthous ulcerations are more
common and measure up to 5 mm. They typically appear
on the unattached gingiva (nonkeratinized mucosa) and
throat, and low-grade fever lasting for several days prior heal within 7 to 10 days. Major aphthous ulcerations are
to the appearance of vesicles in the mouth. In herpan- larger and can arise on the keratinized mucosa (attached
gina, a cluster of four to five vesicles usually is found on gingiva or palatal tissue). Besides being larger, these
the soft palate or tonsillar pillars. The lesions start as red lesions last longer and result in scarring. Both types
macules, which transform into fragile vesicles that rapidly appear as areas of yellow, pseudomembranous slough
ulcerate. The ulcerations are 2 to 4 mm in diameter. with an erythematous border.
Hand, foot, and mouth disease presents with intraoral The cause of RAU remains elusive. Theories range
vesicles in the same location as herpangina, but typically from vitamin deficiency, food allergy (cinnamon, red
with more lesions, as well as vesicles in other places, such dye), and stress to an overactive immune response to
as the palmar surfaces of the hands and plantar surfaces of trauma in the oral cavity. Application of a topical anes-
the feet. The skin lesions are surrounded by an erythem- thetic cream or paste may help in the immediate allevia-
atous margin. Most of the ulcerations from herpangina tion of pain to facilitate eating and mouth care. Special
and hand, foot, and mouth disease resolve spontaneously rinses containing a combination of steroid, antihista-
within 10 days and are less severe than those of primary mine, and antifungal agents–referred to as “magic
herpetic gingivostomatitis. The treatment is symptom- mouthwash”– have been used empirically at many hospi-
atic care. tals. Multivitamin supplements containing vitamin B
complex and vitamin C have been shown to be helpful in
mucosal healing.
Riga-Fede Ulceration
Riga-Fede ulceration is a unique condition that affects
the ventral surface of the tongue in infants (Fig. 6). It is Summary
caused by continual protrusive and retrusive movements Oral health is an integral part of the overall health and
of the tongue over the lower incisors. Treatment varies well-being of children. The ability to recognize, diag-
from conservative observation to smoothing the sharp nose, and treat oral conditions is an important aspect of a
edges of the lower incisors. If the lower incisors have pediatrician’s expertise. The oral conditions described in
erupted prematurely, appearing at birth (natal teeth) or this article can cause significant concern for caregivers
within 30 days of birth (neonatal teeth), the treatment and morbidity for patients. Children and their families
for Riga-Fede ulceration is observation, unless the pre- are well served by pediatricians who make oral health a
mature teeth are excessively mobile, in which case extrac- key component of their daily practices, maintain a work-
tion is indicated. Rarely is extraction of the lower incisors ing knowledge of oral conditions, and collaborate with
indicated unless the child has a challenging oral self- other health professionals (eg, dentists) who have a
abusive condition such as Lesch-Nyhan syndrome. vested interest in child oral health.

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 ear, nose, and throat oral conditions

Editor’s Note HRSA (888-275-4772); electronic versions can be

The August 2006 edition of AAP News reported three found on the OHRC Web site at www.mchoral-
new resources on oral health for special needs children health.org.
available from the National Maternal and Child Oral
Health Resource Center (OHRC):
Suggested Reading
● Special Care: An Oral Health Professional’s Guide to Akintoye SO, Greenberg MS. Recurrent aphthous stomatitis. Dent
Serving Young Children with Special Health Care Clin North Am. 2005;9:31– 47
Needs. This is a 5-module Web-based curriculum for da Fonseca MA. Oral and dental care of local and systemic diseases.
In: Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW,
dentists and dental hygienists. Available at: www. Nowak AJ, eds. Pediatric Dentistry - Infancy through Adoles-
mchoralhealth.org cence. 4th ed. St. Louis, Mo: Elsevier Saunders; 2005:74 –76
● Promoting the Oral Health of Children with Special Fields EA, Brookes V, Tyldesley WR. Recurrent aphthous ulcer-
Health Care Needs—In Support of the National ation in children: a review. Int J Paediatr Dent. 1992;1:1–10
Agenda. This is a policy brief listing the six critical Lalakea ML, Messner AH. Ankyloglossia: does it matter? Pediatr
Clin North Am. 2003;50:381–397
indicators of a comprehensive system of care identified Muzyka BC. Oral fungal infections. Dent Clin North Am. 2005;49:
by the Maternal and Child Health Bureau. 49 – 65
● Oral Health Resource Bulletin: Volume XIV—Focus on Regezi JA, Sciubba JJ, Jordan RCK. Salivary gland diseases. In:
Head Start. This volume offers information about ma- Oral Pathology, Clinical Pathologic Correlations. 4th ed. St.
terials of interest to health professionals and others Louis, Mo: Mosby; 2003:183–185
Stoopler ET. Oral herpetic infections (HSV1– 8). Dent Clin North
working to address the oral health needs of infants, Am. 2005;49:15–29
children, and pregnant women enrolled in Head Start Vazquez JA, Sobel JD. Mucosal candidiasis. Infect Dis Clin North
programs. Am. 2002;16:793– 820
Zhao YF, Jia Y, Chen XM, Zhang WF. Clinical review of 580
Print copies of the bulletin and policy brief are available ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
for no charge at HRSA Information Center, 888-ASK- 2004;98:281–287

Pediatrics in Review Vol.28 No.1 January 2007 21

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ear, nose, and throat oral conditions

PIR Quiz
Quiz also available online at www.pedsinreview.org.

6. A 9-month-old boy has a unilateral soft bluish swelling in the floor of his mouth that has been enlarging.
You diagnose a ranula. The most appropriate treatment is:
A. A prolonged course of oral antibiotics.
B. Excision.
C. Incision and drainage.
D. Injection of hypertonic saline.
E. Observation for spontaneous resolution.

7. A 3-month-old girl who is otherwise well and growing and developing normally has had persistent oral
candidiasis for the past month. She is breastfeeding. Findings on her physical examination, aside from
white plaques on the buccal surfaces, lips, and tongue, are unremarkable. The most likely reason that
treatment with oral nystatin has so far been ineffective is:
A. Failure to give medication as prescribed.
B. Nystatin resistance.
C. Occult malignancy.
D. Occult T-cell disorder.
E. Reinfection from maternal breast.

8. A 2-year-old girl has had persistent oral candidiasis for the past 2 months. Not only does she have white
plaques on the buccal surfaces, lips, and tongue, but she also has red scaling and fissuring at the corners
of her mouth and potassium hydroxide-positive erythematous patches on the palate. The failure of her
candidiasis to respond to appropriate therapy is most likely a result of:
A. A course of amoxicillin for otitis media 2 months ago.
B. Failure to give nystatin as prescribed.
C. Nystatin resistance.
D. Occult immunodeficiency.
E. Reinfection from an untreated toothbrush.

9. You and a resident are examining a newborn who has a short lingual frenulum. In explaining the
condition, you are most likely to state that ankyloglossia:
A. Is likely to produce speech delay.
B. Is more common among females.
C. Is more likely to hamper bottle-feeding than breastfeeding.
D. Is usually asymptomatic.
E. Usually requires a frenectomy.

10. A previously healthy 18-month-old boy is brought in by his mother because of 3 days of fever, drooling,
and decreased oral intake. On physical examination, you find numerous vesicles and ulcers on his gingiva
and tongue, but the remainder of the findings, except for a slight prolongation of capillary refill, are
unremarkable. The best explanation of your findings is:
A. Aphthous ulcerations.
B. Hand, foot, and mouth disease.
C. Herpangina.
D. Primary herpetic stomatitis.
E. Riga-Fede ulcerations.

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 Oral Conditions
David M. Krol and Martha Ann Keels
Pediatrics in Review 2007;28;15
DOI: 10.1542/pir.28-1-15

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 Oral Conditions
David M. Krol and Martha Ann Keels
Pediatrics in Review 2007;28;15
DOI: 10.1542/pir.28-1-15

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http://pedsinreview.aappublications.org/content/28/1/15

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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