Test Bank For Applied Pharmacology for The Dental Hygienist 9th Edition by Elena Bablenis Haveles |

Chapter 01: Information Sources, Regulatory Agencies, Drug Legislation, and Prescription Writing Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Knowledge of pharmacology aids the dental professional in a. obtaining a patient’s health history. b. administering drugs in the office. c. handling emergency situations. d. selection of a nonprescription medication. e. All of the above.

ANS: E

All of the choices are true. Because many of our patients are being treated with drugs, knowledge of pharmacology helps in understanding and interpreting patients’ responses to health history questions.

Knowledge of the therapeutic and adverse effects of medications obviously helps in their proper administration in the office. Emergency situations may be caused by drugs or treated by drugs; thus, knowledge of pharmacology is of great help, especially because a rapid response is sometimes required. A clear understanding of the concepts of drug action, drug handling by the body, and drug interactions will allow the dental practitioner to make proper judgments and grasp the concepts relevant to new drug therapies on the market.

DIF: Application REF: Role of the Dental Hygienist (Medication/Health History), Role of the Dental Hygienist (Medication Administration), Role of the Dental Hygienist (Emergency Situations), Role of the Dental Hygienist (Nonprescription Medication) | pp. 2-3 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following statements is true regarding planning appointments? a. Whether or not patients are taking medication for systemic diseases is of little

consequence in the dental office. b. Asthmatic patients should have dental appointments in the morning. c. Diabetic patients usually have fewer problems with a morning appointment

compared with afternoon appointments. d. Both B and C are true.

ANS: D

Asthmatic patients who experience dental anxiety should schedule their appointments when they are not rushed or under pressure early in the morning. Diabetic patients usually have relatively fewer problems with a morning appointment. Patients taking medication for systemic diseases may require special handling in the dental office.

DIF: Comprehension REF: Role of the Dental Hygienist (Appointment Scheduling) | p. 3 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology

3. Nutritional or herbal supplements a. carry the U.S. Food and Drug Administration (FDA) approval for disease states. b. are not drugs. c. can cause adverse effects. d. will not interact with other drugs the patient may be taking.

ANS: C

Nutritional or herbal supplements are quite capable of causing adverse effects. The majority of nutritional or herbal supplements do not carry FDA approval for treating disease states. These supplements are drugs and can cause adverse effects and interact with different drugs.

DIF: Comprehension REF: Role of the Dental Hygienist (Nutritional or Herbal Supplements) | p. 3 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. Which type of drug name usually begins with a lowercase letter? a. Brand name b. Code name c. Generic name d. Trade name ANS: C

Before any drug is marketed, it is given a generic name that becomes the “official” name of the drug.

Each drug is assigned only one generic name selected by the U.S. Adopted Name Council, and the name is not capitalized. The brand name is equivalent to the trade name and is capitalized. Although the brand name is technically the name of the company marketing the product, this term is often used interchangeably with the trade name. The code name is the initial term used within a pharmaceutical company to refer to a drug while it is undergoing investigation and is often a combination of capital letters and numbers, the letters representing an abbreviation of the company name.

DIF: Comprehension REF: Drug Names | p. 4 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 5. A drug’s generic name is selected by the a. pharmaceutical company manufacturing it. b. Food and Drug Administration (FDA). c. U.S. Adopted Name Council. d. Federal Patent Office.

ANS: C

Each drug is assigned only one generic name (e.g., ibuprofen). It is selected by the U.S. Adopted Name Council. The generic name is not selected by the FDA or the Federal Patent Office. The pharmaceutical company manufacturing the drug clearly has an influence on the generic name given its drug, but the final decision is not the company’s.

DIF: Recall REF: Drug Names | p. 4 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

6. Which of the following is true concerning generic and trade names of drugs? a. A drug may only have one generic name and one trade name.

b. A drug may only have one generic name, but it may have several trade names. c. A drug may have several generic names, but it may only have one trade name. d. A drug may have several generic names and several trade names.

ANS: B

Each drug has only one generic name but may have several trade names. For each drug, there is only one generic name. It is not capitalized, and it becomes the “official” name of the drug. The pharmaceutical company discovering the drug gives the drug a trade name. The trade name is protected by the Federal Patent Law for 20 years from the earliest claimed filing date, plus patent term extensions. Although the brand name is technically the name of the company marketing the product, it is often used interchangeably with the trade name.

DIF: Comprehension REF: Drug Names | p. 4 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 7. Two drugs that are found to be chemically equivalent, but not biologically equivalent or

therapeutically equivalent are said to differ in a. potency. b. efficacy. c. bioavailability. d. therapeutic index.

ANS: C

A preparation can be chemically equivalent yet not biologically or therapeutically equivalent. These products are said to differ in their bioavailability. The potency of a drug is a function of the amount of drug required to produce an effect. The efficacy is the maximum intensity of effect or response that can be produced by a drug. The therapeutic index is the ratio of the lethal dose for 50% of the experimental animals divided by the effective dose for 50% of the experimental animals. If the value of the therapeutic index is small, toxicity is more likely.

DIF: Recall OBJ: 4

REF: Drug Names (Drug Substitution) | p. 5 TOP: NBDHE, 6.0. Pharmacology

8. How many years must pass after a drug patent expires before other drug companies can market the

same compound as a generic drug? a. 20 years b. 17 years c. 7 years d. 0 years ANS: D

Once a drug patent expires, competing companies may immediately market the same compound in generic form. The pharmaceutical company discovering the drug gives the drug a trade name. The trade name is protected by the Federal Patent Law for 20 years from the earliest claimed filing date, plus the patent term extensions.

DIF: Application OBJ: 4

REF: Drug Names (Drug Substitution) | p. 5 TOP: NBDHE, 6.0. Pharmacology

9. Two drug formulations that produce similar concentrations in the blood and tissues after drug

administration are termed a. chemically b. biologically c. therapeutically

equivalent.

ANS: B

Biologic equivalence refers to identical pharmacokinetic parameters of two drug formulations (bioequivalence, for short). Chemical equivalence indicates that two formulations of a drug meet the chemical and physical standards established by the regulatory agencies. Therapeutic equivalence means that two formulations produce the same therapeutic effects over the same duration.

DIF: Application OBJ: 4

REF: Drug Names (Drug Substitution) | p. 5 TOP: NBDHE, 6.0. Pharmacology

10. The federal body that determines whether a drug is considered a controlled substance and to which

schedule it belongs is the a. Food and Drug Administration (FDA). b. Federal Trade Commission (FTC). c. Drug Enforcement Administration (DEA). d. U.S. Pharmacopeia (USP).

ANS: C

The DEA regulates the manufacture and distribution of substances with abuse potential. Hence prescriber DEA numbers must appear on prescriptions for controlled substances. The FDA does not have any special powers in regard to drugs of abuse. The FTC regulates commerce and advertising claims of foods, over-the-counter (OTC) products, and cosmetics. The USP regulates the uniformity and purity of drugs.

DIF: Comprehension REF: Federal Regulations and Regulatory Agencies (US Drug Enforcement Administration) | p. 5 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 11. Which federal regulatory agency decides which drugs require a prescription and which drugs may be

sold over-the-counter (OTC)? a. FDA b. OSHA c. FTC d. DEA ANS: A

The Food and Drug Administration (FDA) is part of Department of Human and Health Services (DHHS), and determines what drugs may be sold by prescription and OTC and regulates the labeling and advertising of prescription drugs. The Occupational Safety and Health Administration (OSHA) ensures the safety and health of workers in the United States by setting and enforcing standards. The Federal Trade Commission (FTC) regulates the trade practices of drug companies and prohibits the false advertising of foods, nonprescription (OTC) drugs, and cosmetics. The Drug Enforcement Administration (DEA) is a part of the Department of Justice and regulates the manufacture and distribution of substances that have a potential for abuse, including opioids, stimulants, and sedatives.

DIF: Recall REF: Federal Regulations and Regulatory Agencies (US Food and Drug Administration) | p. 5 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 12. Which federal regulatory body regulates the trade practices of drug companies and prohibits false

advertising of foods, nonprescription drugs, and cosmetics? a. FDA b. FTC c. DEA d. OBRA ANS: B

Consumers who refer to care labels on their clothes, product warranties, or stickers showing the energy costs of home appliances are using information required by the FTC. Businesses must be familiar with the laws requiring truthful advertising and prohibiting price fixing. These laws are also administered by the FTC. When the FTC was created in 1914, its purpose was to prevent unfair methods of competition in commerce. Over the years, the U.S. Congress has passed additional laws giving the agency greater authority to police anticompetitive practices. The FDA grants approval so that drugs can be marketed in the United States. Before the FDA can approve a drug, the drug must be determined to be both safe and effective. The DEA regulates the manufacture and distribution of substances that have a potential for abuse. OBRA (Omnibus Budget Reconciliation Act) is not a regulatory body; it is an act that mandates that pharmacists must provide patient counseling.

DIF: Recall REF: Federal Regulations and Regulatory Agencies (Federal Trade Commission) | p. 5 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 13. An investigational new drug application (INDA) is submitted a. before preclinical trials b. before phase 1 clinical trials c. after phase 2 clinical trials d. before phase 3 clinical trials

.

ANS: B

Preclinical testing usually lasts about 3 years. After the preclinical trials have been completed, an INDA must be filed with the FDA before a drug company can commence phase 1 clinical trials.

Animal testing data must be accumulated from preclinical trials before filing an INDA. Phase 1 is the first trial using patients, and phases 2 and 3 follow phase 1. An INDA must be filed before any testing in humans can commence.

DIF: Recall OBJ: 6

REF: Clinical Evaluation of a New Drug | p. 5 TOP: NBDHE, 6.0. Pharmacology

14. Phase 1 clinical trials involve all of the following except which one? a. Safe dose range b. Toxic effects of the drug c. Metabolism d. Effectiveness ANS: D

In phase 1 clinical trials, small and then increasing doses are administered to a limited number of healthy human volunteers, primarily to determine safety. This phase determines the biologic effects, metabolism, safe dose range in humans, and toxic effects of the drug. The main purpose of phase 2 is to test effectiveness. Biologic effects, metabolism, safe dose range in humans, and toxic effects of the drug are, in fact, goals of phase 1 clinical trials.

DIF: Comprehension REF: Clinical Evaluation of a New Drug | p. 5 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 15. Which of the following is determined during a phase 3 clinical evaluation of a new drug? a. Effectiveness b. Safety and efficacy c. Dosage d. Both A and B e. Both B and C ANS: E

Both safety and efficacy must be demonstrated during phase 3 of the clinical evaluation of a new drug.

Dosage is also determined during this phase. During phase 3, clinical evaluation takes place involving a large number of patients who have the condition for which the drug is indicated. The main purpose of phase 2 clinical evaluation is to test a drug’s effectiveness.

DIF: Recall OBJ: 6

REF: Clinical Evaluation of a New Drug | p. 6 TOP: NBDHE, 6.0. Pharmacology

16. Which of the following is a Schedule II controlled substance? a. Heroin b. Propranolol c. Amphetamine d. Dextropropoxyphene (Darvon) ANS: C

Amphetamine, oxycodone, morphine, and secobarbital are all schedule II controlled substances.

Heroin is a schedule I substance. Propranolol is a nonscheduled prescription drug.

Dextropropoxyphene is a schedule IV substance.

DIF: Recall REF: Drug Legislation (Scheduled Drugs [Table 1.2: Schedules of Controlled Substances]) | p. 6 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 17. Controlled substances in schedule

and do not permit refills. a. II, III, and IV b. II and III c. III and IV d. II only e. III only ANS: D

require a written prescription with the provider’s signature

Controlled substances in schedule II require a written prescription with the provider’s signature and do not permit refills. Any prescription for schedule II drugs must be written in pen or indelible ink or typed. A designee of the dentist, such as the dental hygienist, may write the prescription, but the prescriber must personally sign the prescription in ink and is responsible for what any designee has written. Prescriptions for controlled substances in both schedule III and schedule IV may be telephoned, and no more than five prescriptions in 6 months are permitted.

DIF: Comprehension REF: Drug Legislation (Scheduled Drugs) | p. 6 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 18. Schedule III controlled substances may be telephoned to the pharmacist and may be refilled no more

than five times in 6 months. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: A

Both parts of the statement are true. Schedule III controlled substances may be telephoned to the pharmacist and may be refilled as many as five times in 6 months. Both parts of the statement are true for schedule III and schedule IV controlled substances. Schedule I controlled substances have no accepted medical use. Schedule II controlled substances require a written prescription with the provider’s signature, and no refills are permitted. Schedule V controlled substances can be bought OTC in some states.

DIF: Recall OBJ: 7

REF: Drug Legislation (Scheduled Drugs) | p. 6 TOP: NBDHE, 6.0. Pharmacology

19. What is the purpose of a “black box warning” on a package insert? a. It is used to reconstruct the events leading to a fatality resulting from a medication

error. b. It is issued by the Drug Enforcement Administration (DEA) to indicate

medications that may be used to manufacture illicit drugs such as methamphetamine. c. It is used to draw attention to potentially fatal, life threatening, or disabling adverse effects for different medications. d. It means that the effects of the drug have not yet been determined.

ANS: C

A black box warning is about a drug the FDA has required a manufacturer to prominently display in a box in the package insert. The intent of the black box is to draw attention to the specific warning and make sure that both the prescriber and patient understand the serious safety concerns associated with that drug. A black box on an airplane is used to reconstruct events prior to a tragedy; however, the black box warning on a medication package insert is used to warn about safety concerns with the drug.

A black box is not used as a warning about illicit use of medications. All drugs must go through preclinical and clinical trials prior to being marketed.

DIF: Recall OBJ: 7

REF: Drug Legislation (Black Box Warning) | pp. 6-7 TOP: NBDHE, 6.0. Pharmacology

20. An “orphan drug” is a. not related to any other medication currently available. b. developed specifically to treat a rare medical condition. c. a drug that has been on the market for longer than 20 years and generic substitution

is permitted. d. no longer available for use as newer, more effective medications are available.

ANS: B

Rare medical conditions with orphan status refer to diseases that occur in fewer than 200,000 people in the United States. Orphan drugs may be related to other medications. Orphan drug status is not related to the time the drug has been available. Many newer drugs have been assigned orphan status.

DIF: Recall OBJ: 7

REF: Drug Legislation (Orphan Drugs) | p. 7 TOP: NBDHE, 6.0. Pharmacology

21. The word stat on a prescription means a. before meals. b. at bedtime. c. immediately. d. every.

ANS: C

The word stat on a prescription means immediately (now). The abbreviation ac means before meals, hs means at bedtime, and q means every.

DIF: Recall OBJ: 7

REF: Table 1.3: Abbreviations Commonly Used in Prescriptions | p. 8 TOP: NBDHE, 6.0. Pharmacology

22. The abbreviation used on prescriptions for four times a day is a. bid. b. qid. c. qd. d. ud.

ANS: B

qid is the abbreviation for quarter in die, or four times a day. bid stands for twice a day, qd stands for every day, and ud stands for as directed.

DIF: Recall REF: Prescription Writing (Prescription Label Regulations [Table 1.3: Abbreviations Commonly Used in Prescriptions]) | pp. 8-9 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 23. The heading of a prescription contains the following information except the a. name and address of the prescriber. b. name and address of the patient. c. telephone numbers of the patient and the prescriber. d. date of birth of the prescriber. e. date of the prescription.

ANS: D

Including the date of birth of the patient on the prescription is important, both to determine the proper dose for age and also the patient is not confused with another family member (i.e., mother or daughter). The heading of a prescription contains the name, address, and telephone number of the prescriber, as well as the name, address, age, and telephone number of the patient, and the date of the prescription.

DIF: Comprehension REF: Prescription Writing (Prescriptions [Format]) | p. 7 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 24. Which of the following is located in the body of the prescription? a. The date of the prescription b. The amount of the drug to be dispensed c. Directions to the prescriber d. Refill instructions ANS: B

The Rx symbol, name and dose size or concentration of the drug, amount to be dispensed, and directions to the patient are all found in the body of the prescription. The date of the prescription is found in the heading. The directions to the patient rather than prescriber are found in the body of the prescription. Refill instructions are found in the closing of the prescription.

DIF: Recall OBJ: 7

REF: Prescription Writing (Prescriptions [Format]) | p. 8 TOP: NBDHE, 6.0. Pharmacology

25. Where is the information regarding the prescriber DEA number commonly found on the prescription? a. Superscription b. Heading c. Body d. Closing ANS: D

The signature area of the prescription is found in the closing. It should also include a space for the DEA number. The superscription is a classical description for where the patient information and the symbol Rx are found. The heading contains prescriber and patient contact information, the patient’s date of birth, and the date of prescription. The body contains the Rx symbol, dosage instructions, and directions to the patient.

DIF: Recall OBJ: 7

REF: Prescription Writing (Prescriptions [Format]) | p. 8 TOP: NBDHE, 6.0. Pharmacology

26. On a prescription, the directions to the patient are preceded by a. Rx. b. Sig. c. #. d. Disp.

ANS: B

Sig. is the abbreviation for the Latin word signa, or write. This word precedes the instructions to the patient. Rx means take thou and precedes the prescription instructions, # denotes the number of tablets, capsules, and so forth to be dispensed. Disp. is short for dispense and precedes the amount to be dispensed, analogous to #.

DIF: Recall OBJ: 7

REF: Prescription Writing (Prescriptions [Format]) | p. 8 TOP: NBDHE, 6.0. Pharmacology

27. Each is an advantage of electronic and fax prescribing except one. Which is the exception? a. It reduces the likelihood of errors in reading handwritten prescriptions. b. It reduces the patient’s ability to tamper with a prescription. c. There is no record of the prescription in the patient’s record. d. Prescriptions can be faxed to the pharmacy.

ANS: C

A written record of the prescription is kept in the patient’s record. Electronic prescribing is the electronic transmission of a prescription to a pharmacy, which reduces the incidence of errors in reading handwritten prescriptions and the patient’s ability to tamper with a prescription. Prescriptions can be faxed to the pharmacy.

DIF: Comprehension REF: Prescription Writing (Prescriptions [Electronic and Fax Prescribing]) | p. 9 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 28. Which drug legislation act was instrumental for the growth of electronic prescribing? a. Controlled Substance Act b. Medicare Modernization Act c. Food, Drug and Cosmetic Act d. Harrison Narcotic Act ANS: B

The inclusion of e-prescribing in the Medicare Modernization Act of 2003 (MMA) gave momentum to its use in provider practices across the country. The MMA expanded Medicare to include a drug benefit program (Medicare Part D), which began in 2006. Electronic prescribing of controlled substances as mandated by the federal SUPPORT Act of 2018 went into effect in January of 2021.

This federal mandate affects Medicare Part D prescription plans. Any prescription for a controlled substance written for a Medicare Part D patient must be electronically prescribed. Many states have passed legislation that mandates that any opioid prescription (regardless of insurer) must be electronically prescribed. This legislation has been passed in an attempt to prevent prescription diversion and tampering. The Controlled Substance Act of 1970 replaced the Harrison Narcotic Act of 1914, and the Drug Abuse Control Amendments (1965) to the Food, Drug and Cosmetic Act (1938).

DIF: Comprehension REF: Prescription Writing (Prescriptions [Electronic and Fax Prescribing]) | p. 9 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 29. What would be an advantage for a dentist to call the pharmacy with a prescription for Tylenol #3

rather than hydrocodone for a patient who calls late at night requesting medication for pain following root canal therapy? a. Tylenol #3 is available over-the-counter and does not require a prescription.

b. Tylenol #3 is a not a controlled substance and hydrocodone is a controlled

substance. c. A prescription for Tylenol #3 (Schedule III) may be telephoned, whereas

hydrocodone (Schedule II) requires a written prescription. d. Tylenol #3 has greater potency than hydrocodone.

ANS: C

Tylenol #3 has moderate abuse potential and prescriptions may be telephoned. Hydrocodone has high abuse potential and requires a written prescription with the provider’s signature. Tylenol #3 is a Schedule III controlled substance. It is not available over-the-counter and requires a prescription.

Hydrocodone has more potency and a higher abuse potential than Tylenol #3.

DIF: Application REF: Drug Legislation (Scheduled Drugs [Table 1.2: Schedules of Controlled Substances]) | p. 6 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 30. Clinical studies of drugs first involve human volunteers during which phase of drug testing? a. Phase 1 b. Phase 2 c. Phase 3 d. Phase 4 ANS: A

Clinical studies of drugs involve humans’ right from the start of Phase 1 clinical trials. In Phase 1 clinical trials, small and then increasing doses of the prospective drug are administered to a limited number of healthy human volunteers, primarily to determine safety. Larger groups of humans are given the drug in Phase 2 clinical trials, but humans were involved in Phase 1 clinical trials. Phase 3 involves a large number of patients who have the condition for which the drug is indicated. Phase 4 involves postmarketing surveillance.

DIF: Recall OBJ: 6

REF: Clinical Evaluation of a New Drug | p. 5 TOP: NBDHE, 6.0. Pharmacology

MULTIPLE RESPONSE 1. How are computer and online resources enhancing printed books as a source of information about

drugs? (Select all that apply.) a. Web-based physicians can diagnose patient conditions and prescribe medication over the Internet. b. Tablet computers and smart phones may be used for medication information databases. c. Some publishers have apps that can be downloaded to smart phones. d. Websites such as WebMD have decision trees whereby patients can identify their own health condition and determine appropriate treatment and medication. e. Older editions of textbooks have been placed in the public domain and are useful for information about medications and drug interactions.

ANS: B, C

Tablet computers and smart phones are being used more and more for recording, storing patient information, calculating drug doses, and using medication information databases. Some online websites have apps that can be downloaded to smart phones as well as computer-based online sites.

There are many legal issues with health care professionals dispensing advice over the Internet. For example, a health care provider may not be licensed to practice in the state where the person asking for information resides. Websites do not provide the means for patients to determine their own health condition. There are many sites with useful information, but most have a disclaimer recommending that the person seek help from a qualified practitioner. Medications change rapidly, and it is important to use current sources of information.

DIF: Comprehension REF: Sources of Information (Computers and Online Resources) | p. 4 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following are true of an off-label use of a drug? (Select all that apply.) a. Prescribers are allowed to use drugs for off-label use under certain circumstances. b. The FDA approves the use of drugs for specific indications, which are listed or

labeled on the package insert of the drug. c. Drug manufacturers have much useful information regarding off-label uses of their drugs on their websites. d. Off-label use of drugs is not permitted in the United States. e. Off-label drugs are repackaged for sale by clandestine organizations outside the United States and are illegal to transport or distribute.

ANS: A, B

Practitioners are allowed to use off-label drugs if good medical practice justifies their use, the use is well documented in the medical literature, and the drug meets the current standard of medical care.

The FDA approves the use of drugs for specific indications, and they are listed or labeled on the package insert of the drug. Drug manufacturers are not allowed to bring up off-label uses when speaking with the prescribing practitioner, nor can they distribute written material regarding off-label uses. The off-label use of drugs is permitted in the United States provided that several rules are followed.

DIF: Comprehension REF: Drug Legislation (Labeled and Off-Label Uses) | p. 7 TOP: NBDHE, 6.0. Pharmacology

OBJ: 7

3. Which of the following are associated with increased patient nonadherence to medication therapy?

(Select all that apply.) a. Some patients may fear of the side effects of the medication. b. A longer duration of drug therapy is associated with the risk for nonadherence with medication therapy. c. Increased dosing frequency is associated with nonadherence with medication therapy. d. The issue of nonadherence to medication therapy is not important, as patients reliably take their medication as prescribed.

ANS: A, B, C

Many factors are associated with nonadherence to medication therapy. These include poor understanding of the disease and a need for medication to treat it, fear of side effects of the medication, distrust of health care professionals, economic factors, or forgetfulness. Longer duration of drug therapy and the number of times a day the patient must take a prescription increase the chances that a patient will not adhere to the regimen. For example, patients are more compliant with twice-a-day dosing than they are with four-times-a-day dosing. Statistics reveal that only a minority of patients will take their medication as prescribed.

DIF: Comprehension REF: Prescription Writing (Role of the Dental Hygienist and Patient Adherence to Medication Therapy) | p. 9 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. The body of a prescription includes directions to the patient.

ANS: T

The body of the prescription contains the Rx symbol, name, and dose size or concentration of the drug, amount to be dispensed, and directions to the patient.

DIF: Recall OBJ: 7

REF: Prescription Writing (Prescriptions [Format]) | p. 8 TOP: NBDHE, 6.0. Pharmacology

2. Refill instructions are found in the body of a prescription.

ANS: F

Refill instructions are found in the closing, rather than body, of the prescription.

DIF: Recall OBJ: 7

REF: Prescription Writing (Prescriptions [Format]) | p. 8 TOP: NBDHE, 6.0. Pharmacology

Chapter 02: Drug Action and Handling Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. A drug is defined as a biologically active substance that can modify a. the environment. b. the pH of tissue. c. cellular function. d. immune response.

ANS: C

A drug can modify cellular function. A general understanding of drug action allows the dental hygienist to make informed decisions regarding possible drug interactions or adverse reactions for the patient. It is a concern that discarded drugs may be affecting the environment, but this is not the definition of a drug. Some drugs may have the capacity to modify body compartment pH; however, this is not the definition for a drug. Some drugs may have the capacity to modify the immune response, but this is not the definition of a drug.

DIF: Recall REF: Introduction | p. 11 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. In comparing two drugs, the dose-response curve for the drug that is more efficacious would a. be closer to the y-axis. b. be farther from the y-axis. c. have a greater curve height. d. have a higher median effective dose (ED50).

ANS: C

Efficacy is an expression of maximum intensity of effect or response that can be produced by a drug.

The other choices refer to indicators of drug potency, not efficacy. The potency of a drug is a function of the amount of drug required to produce an effect. The potency of drug is shown by the location of that drug’s curve along the log-dose axis (x-axis).

DIF: Comprehension REF: Characterization of Drug Action (Efficacy) | p. 11 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. Administering a drug of greater potency is better because drugs of greater potency do not require as

high a dose. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: D

The first part of the statement is false, the second part is true. The absolute potency of a drug is immaterial as long as the appropriate dose is administered. If equally efficacious, both drugs will produce the same effect. Both meperidine and morphine, for example, have the ability to treat severe pain, but approximately 100 mg of meperidine would be required to produce the same action as 10 mg of morphine. The dose of meperidine needed to produce pain relief is larger than that for morphine.

Less potent drugs require higher doses to produce therapeutic effects whereas more potent drugs can reach toxic levels at lower doses.

DIF: Application OBJ: 1

REF: Characterization of Drug Action (Potency) | p. 11 TOP: NBDHE, 6.0. Pharmacology

4. Which of the following statements is true regarding the therapeutic index (TI) of a drug? a. A drug with a large TI is more dangerous than a drug with a small TI. b. The formula for TI is ED50/LD50. c. ED50 is 50% of the effective clinical dose. d. TI is the ratio of the median lethal dose to the median effective dose.

ANS: D

LD50 is the dose causing death in 50% of test animals and ED50 is the dose required to produce the desired clinical effect in 50% of test animals. The greater the TI, the safer the drug. The formula is TI = LD50/ED50. The ED50 is the dose required to produce the desired clinical effect in 50% of test animals, not 50% of the effective clinical dose.

DIF: Comprehension REF: Characterization of Drug Action (Therapeutic Index) | p. 12 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Which of the following statements is true concerning the mechanism of action of drugs? a. Drugs are capable of imparting a new function to the organism. b. Drugs either produce the same action as an exogenous agent or block the action of

an exogenous agent. c. Drugs either produce the same action as an exogenous agent or block the action of an endogenous agent. d. Drugs either produce the same action as an endogenous agent or block the action of an endogenous agent.

ANS: D

Drugs either produce the same action as an endogenous agent or block the action of an endogenous agent. Drugs do not impart a new function to the organism; they merely either produce the same action as an endogenous agent or block the action of an endogenous agent.

DIF: Comprehension REF: Mechanism of Action of Drugs | pp. 12-13 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. When different drugs compete for the same receptor sites, the drug with the stronger affinity for the

receptor will bind to a. more receptors than the drug with the weaker affinity. b. fewer receptors than the drug with the weaker affinity. c. all of the available receptors. d. none of the available receptors.

ANS: A

When different drugs compete for the same receptor sites, the drug with the stronger affinity for the receptor will bind to more receptors than the drug with the weaker affinity. More of the drug with weaker affinity will be required to produce a pharmacologic response. Drugs with a stronger affinity for receptor sites are more potent than drugs with weaker affinities for the same site.

DIF: Recall OBJ: 2

REF: Mechanism of Action of Drugs (Receptors) | p. 13 TOP: NBDHE, 6.0. Pharmacology

7. When a drug has affinity for a receptor and produces no effect, it is called a(n) a. agonist. b. competitive antagonist. c. competitive agonist. d. physiologic agonist.

ANS: B

A competitive antagonist has affinity for a receptor, combines with the receptor, competes with the agonist for the receptor, and produces no effect. An agonist has affinity for a receptor, combines with the receptor, and produces an effect. Competitive agonist is nonsensical terminology. A physiologic antagonist has affinity for a site different from that of the agonist in question.

DIF: Recall

REF: Mechanism of Action of Drugs (Receptors [Agonists and Antagonists]) | p. 13 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. A noncompetitive antagonist a. binds to the same receptor site as the binding site for the agonist. b. causes a shift to the right in the dose-response curve. c. enhances the maximal response of the agonist. d. reduces the maximal response of the agonist.

ANS: D

A noncompetitive antagonist reduces the maximal response of the agonist. Noncompetitive antagonists bind to a receptor site that is different from the binding site for the agonist. A competitive antagonist will cause a shift to the right in the dose-response curve.

DIF: Recall REF: Mechanism of Action of Drugs (Receptors [Agonists and Antagonists]) | p. 13 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Which of the following is not a subject of pharmacokinetics? a. Physiologic action of drugs b. Metabolism of drugs c. Elimination of drugs d. Absorption of drugs ANS: A

The physiologic action of drugs is a subject of pharmacology, not pharmacokinetics. Pharmacokinetics does have to do with the subjects of absorption, distribution, metabolism, and excretion of drugs.

DIF: Comprehension REF: Pharmacokinetics | p. 14 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 10. Which of the following statements is (are) true concerning passage across body membranes? a. The membrane lipids make the membrane relatively permeable to ions and polar b.

c. d. e.

molecules.

The lipid molecules orient themselves so that they form a fluid bimolecular leaflet structure with the hydrophobic ends of the molecules shielded from the surrounding aqueous environment.

Membrane carbohydrates make up the structural components of the membrane and help move the molecules across the membrane during the transport process.

Both A and B are true.

Both B and C are true.

ANS: B

The lipid molecules orient themselves so that they form a fluid bimolecular leaflet structure with the hydrophobic ends of the molecules shielded from the surrounding aqueous environment. The hydrophilic ends are in contact with water. The membrane lipids make the membrane relatively impermeable to ions and polar molecules. Membrane proteins make up the structural components of the membrane and help move the molecules across the membrane during the transport process.

DIF: Comprehension

REF: Pharmacokinetics (Passage Across Body Membranes) | p. 14 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 11. Which of the following choices is the process by which a substance is transported against a

concentration gradient? a. Passive transfer b. Active transport c. Facilitated diffusion d. Filtration ANS: B

Active transport is a mechanism for movement of substances, often against a concentration gradient, that uses the energy of the cell to actively pump the substance from one side of a membrane to the other. Passive transfer and filtration entail the passage of substances in a manner proportional to their concentration on each side of the membrane. The substances move without any assistance. Facilitated transport uses a carrier protein but cannot transport substances against a gradient.

DIF: Recall REF: Pharmacokinetics (Passage Across Body Membranes [Specialized Transport]) | p. 14 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 12. Drugs that are weak electrolytes will cross body membranes best when they are (1) nonionized, (2)

ionized, (3) polar, (4) nonpolar, (5) lipid soluble, (6) water soluble. a. 1, 3, 5 b. 1, 3, 6 c. 1, 4, 5 d. 1, 4, 6 e. 2, 4, 5 ANS: C

Drugs that are weak electrolytes will cross body membranes best when they are nonionized, nonpolar, and lipid soluble. These drugs dissociate in solution and equilibrate into a nonionized form and an ionized form. The nonionized, or uncharged, portion acts as a nonpolar, lipid-soluble compound that readily crosses body membranes. The ionized portion of drugs that are weak electrolytes will traverse membranes with greater difficulty because they are less lipid soluble.

DIF: Comprehension REF: Pharmacokinetics (Passage Across Body Membranes [Effect of Ionization]) | p. 15 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 13. Increasing the pH of a solution will cause a. a greater percentage of a weak base in the solution to be in the ionized form. b. a greater percentage of a weak acid in the solution to be in the un-ionized form. c. the hydrogen ion concentration to increase. d. a greater percentage of a weak base in the solution to be in the un-ionized form. e. no change in the relative ionization of weak acids or weak bases.

ANS: D

Weak bases become ionized at low pH and un-ionized at higher pH. If the pH of the site rises, the hydrogen ion concentration will fall. For weak bases, this results in the un-ionized form (B), which can more easily penetrate tissues. Conversely, if the pH of the site falls, the hydrogen ion concentration will rise. This results in an increase in the ionized form (BH+), which cannot easily penetrate tissues.

DIF: Comprehension REF: Pharmacokinetics (Passage Across Body Membranes [Effect of Ionization]) | p. 15 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 14. When the acidity of the tissue increases, as in instances of infection, the effect of a local anesthetic

decreases; therefore, the local anesthetic is a weak acid. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: C

The first part of the statement is true, the second part is false. Infections lead to an accumulation of acidic waste products, which lowers the pH of the local area. Local anesthetics must penetrate the nerve cell membrane to cause their action. They become more ionized as the pH drops. This property is a characteristic of weak bases, not weak acids. Local anesthetics are weak bases. Weak bases are better absorbed when the pH is greater than the pKa. A weak base is associated and ionized when the pH is less than the pKa. DIF: Comprehension REF: Pharmacokinetics (Passage Across Body Membranes [Effect of Ionization]) | p. 15 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 15. Which of the following is true regarding basic principles of drug distribution in the bloodstream? a. All drugs in the blood are either bound to plasma proteins or free. b. Only the drug that is bound to plasma proteins can exert the pharmacologic effect. c. Only the drug that is bound to plasma proteins can pass across cell membranes. d. The free drug is a reservoir for the drug.

ANS: A

All drugs in the blood are either bound to plasma proteins or free. Only the drug that is free can exert the pharmacologic effect. Only the free drug can pass across cell membranes. The bound drug is a reservoir for the drug.

DIF: Comprehension REF: Pharmacokinetics (Distribution [Basic Principles]) | p. 15 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 16. The movement of a drug from one site in the body to other sites is called a. distribution. b. disruption. c. dispersion. d. active transport.

ANS: A

Distribution is the movement of a drug from the site of absorption or injection to other sites.

Disruption is the initial destruction of a tablet coating or capsule during oral absorption. Dispersion is the spread of concentrated drug particles throughout the stomach or intestines. Active transport is a process involved in the passage of certain agents, including some drugs, across membrane barriers and may be involved in not only drug redistribution but also drug absorption, distribution, or excretion.

DIF: Comprehension REF: Pharmacokinetics (Distribution [Basic Principles]) | p. 15 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 17. The distribution of a drug is determined by a. blood flow to the organ. b. presence of certain barriers. c. plasma protein–binding capacity. d. solubility of the drug. e. All of the above.

ANS: E

All of the above choices are correct. If the blood circulation to an organ is low, it will receive less drug. The more membranes and barriers a drug needs to cross, the slower the rate at which it will reach the organ in question. The binding of drugs to plasma proteins reduces the concentration of drug that can leave the circulation and be taken up by an organ. The relative level of fat or water solubility of a drug will influence where and how rapidly a drug will distribute. The distribution of a drug is determined by several factors, such as the size of the organ, the blood flow to the organ, the solubility of the drug, the plasma protein–binding capacity, and the presence of certain barriers (e.g., blood-brain barrier, placenta).

DIF: Recall OBJ: 3

REF: Pharmacokinetics (Distribution [Basic Principles]) | p. 15 TOP: NBDHE, 6.0. Pharmacology

18. If one dose of a drug is administered and the drug’s half-life in the body is 3 hours, what percentage of

the drug would be left after four half-lives? a. 50% b. 6.25% c. 2% d. Insufficient information to determine ANS: B

The half-life is the time required for a drug level to fall to one half of its concentration. The drug concentration would go to 50%  25%  12.5%  6.25% in four half-lives. The information given is more than sufficient to answer the question. One needs merely to count the number of half-lives and divide the percentage drug in half for every half-life passed since the drug was administered.

DIF: Application OBJ: 5

REF: Clinical Pharmacokinetics (Half-Life) | p. 18 TOP: NBDHE, 6.0. Pharmacology

19. One dose of a drug is administered that has a half-life of 8 hours. Assuming first-order kinetics, how

much time is needed for this drug to be over 96% eliminated from the body? a. 8 hours

b. 40 hours c. 60 hours d. 120 hours ANS: B

Assuming first-order kinetics, 40 hours would be required for this drug to be over 96% eliminated from the body. Five half-lives are needed to reduce the levels of a drug to 3.125% of the original levels, or eliminate over 96%. For a drug with an 8-hour half-life, this amounts to five half-lives  8 hours per half-life, or 40 hours.

DIF: Application OBJ: 5

REF: Clinical Pharmacokinetics (Kinetics) | p. 18 TOP: NBDHE, 6.0. Pharmacology

20. The half-life of a drug is most related to its a. onset. b. duration. c. safety. d. time to peak concentration.

ANS: B

Half-life is the amount of time required for a drug to fall to one half of its blood level. It is an expression of how long the drug lasts in the body. Onset is the time at which a drug starts to take effect. The half-life does not predict the relative safety of a drug; safe drugs can have long or short half-lives. Time to peak concentration refers to how much time is required for a drug to reach effective levels in the body, not how long a drug lasts in the body.

DIF: Comprehension REF: Clinical Pharmacokinetics (Half-Life) | p. 18 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 21. Enterohepatic circulation of a drug involves the secretion of a metabolized drug into the intestine. If

enterohepatic circulation is blocked, the level of the drug in the serum will fall. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false. d. The first statement is false, the second statement is true.

ANS: A

Both statements are true. Enterohepatic circulation involves the secretion of a metabolite, such as a conjugated drug, via the bile into the intestine. While in the intestine, the metabolite is broken down (deconjugated), and the active drug can be reabsorbed into the circulation. If this process is blocked, then the reactivated drug cannot reenter the circulation, and the serum level will fall accordingly. Both of the statements are true as written. The circular pattern continues with some drug escaping with each passing. This process prolongs the effect of a drug.

DIF: Comprehension REF: Pharmacokinetics (Distribution [Enterohepatic Circulation]) | p. 16 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 22. If redistribution occurs between specific sites and nonspecific sites, a drug’s action will be a. prolonged.

b. extended. c. decreased. d. terminated.

ANS: D

If redistribution occurs between specific sites and nonspecific sites, a drug’s action will be terminated.

Redistribution of a drug is the movement of a drug from the site of action to nonspecific sites of action.

A drug’s duration of action can be affected by redistribution of the drug from one organ to another.

DIF: Recall OBJ: 4

REF: Pharmacokinetics (Redistribution) | p. 16 TOP: NBDHE, 6.0. Pharmacology

23. The is the most common site for biotransformation. a. kidney b. blood plasma c. liver d. small intestine ANS: C

The liver is the most common site for biotransformation. Biotransformation is the body’s way of changing a drug so that the kidneys can more easily excrete it. The liver rather than kidney, blood plasma, or small intestine is the most common site for biotransformation.

DIF: Comprehension REF: Pharmacokinetics (Metabolism (Biotransformation)) | p. 16 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 24. The metabolite formed during metabolism (biotransformation) is usually _

polar and

lipid

soluble than its parent compound. a. more; more b. more; less c. less; more d. less; less ANS: B

The metabolite is usually more polar and less lipid soluble than its parent compound, meaning that renal tubular reabsorption of the metabolite will be reduced because reabsorption favors lipid-soluble compounds. Metabolites are also less likely to bind to plasma or tissue proteins and less likely to be stored in fat tissue. Drugs must pass through various membranes such as cellular membranes, blood capillary membranes, and intracellular membranes. The lipid in the membranes makes them relatively impermeable to ions and polar molecules. Decreased renal tubular absorption, decreased binding to the plasma or tissue proteins, and decreased fat storage cause the metabolite to be excreted more easily.

DIF: Recall OBJ: 3

REF: Pharmacokinetics (Metabolism (Biotransformation)) | p. 16 TOP: NBDHE, 6.0. Pharmacology

25. All of the following choices are true with regard to cytochrome P-450 hepatic microsomal enzymes

except that they a. can be induced to speed up drug metabolism. b. can be inhibited to slow down drug metabolism.

c. exist as numerous isoenzymes. d. inactivate drugs through conjugation reactions.

ANS: D

Cytochrome P-450 hepatic microsomal enzymes inactivate drugs but not through conjugation. They are involved in phase I metabolism and metabolize drugs through oxidation, reduction, and hydrolysis reactions. Phase II reactions involve conjugation with glucuronic acid, sulfuric acid, acetic acid, or an amino acid. Cytochrome P-450 hepatic microsomal enzymes can be induced to speed up drug metabolism or inhibited to reduce or slow down drug metabolism. They exist as numerous isozymes that have specificity for certain drugs. Examples of isoenzymes include cytochrome P-450 and 3A4.

DIF: Application REF: Pharmacokinetics (Metabolism (Biotransformation) [First-Pass Effect]) | p. 16 | Pharmacokinetics (Metabolism (Biotransformation [Cytochrome P-450 Induction and Inhibition]) | p. 16 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 26. Which of the following reactions is considered to be in the category of phase II drug metabolism? a. Conjugation b. Reduction c. Hydrolysis d. Oxidation ANS: A

Phase II reactions involve conjugation with glucuronic acid, sulfuric acid, acetic acid, or an amino acid. The most common conjugation occurs with glucuronic acid. Reduction, hydrolysis, and oxidation are all examples of phase I drug metabolism.

DIF: Recall REF: Pharmacokinetics (Metabolism (Biotransformation) [First-Pass Effect]) | p. 16 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 27. If a drug displays zero-order elimination kinetics a. elimination increases as the dose of the drug is increased. b. a constant amount is eliminated per unit time. c. the drug is not eliminated and is retained in the body. d. the elimination of the drug cannot be predicted mathematically.

ANS: B

With zero-order kinetics, the metabolism or excretion mechanisms for a drug in the body are saturated, meaning that they are at their maximal level. If more drug is given, then the body cannot keep up, and the drug levels will increase. The body cannot adjust to more drug, and elimination of a drug will remain the same as the dose of the drug is increased. If the drug is eliminated but a longer time is required, then it would for a first-order elimination. The elimination of the drug can be mathematically predicted.

DIF: Comprehension REF: Clinical Pharmacokinetics (Kinetics) | p. 18 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 28. Which of the following processes in the kidney can result in retention of a drug in the body? a. Glomerular filtration

b. Active tubular secretion c. Passive tubular diffusion d. All of the above ANS: C

Passive tubular diffusion is a process whereby solutes such as drugs, which are concentrated in the renal tubular fluid, can diffuse out of the tubule and back into the circulation. The drugs must be unionized and lipid soluble to passively diffuse back to the circulation. Glomerular filtration and active tubular secretion are ways in which drugs and their metabolites enter the renal tubular fluid on their way to the collecting duct and the urine.

DIF: Application OBJ: 3

REF: Pharmacokinetics (Metabolism (Biotransformation) [Excretion]) | p. 17 TOP: NBDHE, 6.0. Pharmacology

29. Which is true regarding excretion when tubular urine is more alkaline? a. Both weak acids and weak bases are excreted more rapidly. b. Weak acids are excreted more rapidly, and weak bases are excreted more slowly. c. Weak acids are excreted more slowly, and weak bases are excreted more rapidly. d. Both weak acids and weak bases are excreted more slowly.

ANS: B

The process of passive tubular diffusion favors the reabsorption of nonionized, lipid-soluble compounds. The more ionized, less lipid-soluble metabolites have more difficulty penetrating the cell membranes of the renal tubules and are likely to be retained in the tubular fluid and eliminated in the urine. When tubular urine is more alkaline, weak acids are excreted more rapidly and weak bases are excreted more slowly. When the tubular urinary pH is more acid than the plasma, weak acids are excreted more rapidly and weak bases are excreted more slowly.

DIF: Recall OBJ: 3

REF: Pharmacokinetics (Metabolism (Biotransformation) [Excretion]) | p. 17 TOP: NBDHE, 6.0. Pharmacology

30. Which term refers to the time required for a drug to begin to have its effect? a. First pass b. Duration c. Onset d. Efficacy ANS: C

Onset is the time at which a drug starts to take effect. First pass refers to the metabolism of drugs by the liver during their movement from the gastrointestinal tract to the systemic circulation via the portal circulation. Duration is the amount of time the drug is active in the body. Efficacy is an assessment of the effectiveness of a drug and does not refer to how quickly or how long a drug acts in the body.

DIF: Recall REF: Routes of Administration and Dose Forms (Routes of Administration) | p. 19 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 31. An enteral route of administration would be a. intravenous. b. oral.

c. sublingual. d. transdermal.

ANS: B

Enteral means situated or occurring inside of the gastrointestinal tract (intestines). Intravenous, sublingual, and transdermal routes of administration bypass the gastrointestinal tract.

DIF: Recall REF: Routes of Administration and Dose Forms (Routes of Administration) | p. 19 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 32. What of the following choices is considered the safest, least expensive, and most convenient route for

administering drugs? a. Inhalation b. Rectal c. Oral d. Subcutaneous ANS: C

Oral administration requires no sophisticated devices, is slow enough in onset to gauge reactions and stop the next dose, and is easy for a patient to administer without assistance. Inhalation and subcutaneous administration require devices, such as inhalers and needles, and the drug is irretrievable once administered. Rectal dosing has lower patient acceptance, and absorption can be variable.

DIF: Recall REF: Routes of Administration and Dose Forms (Routes of Administration) | p. 19 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 33. Advantages of oral administration of a drug include all the following except a. large surface area for drug absorption. b. many different dose forms that may be administered orally. c. more predictable response than intravenous administration. d. the simplest way to introduce a drug into the body.

ANS: C

Intravenous administration offers a more predictable response than the oral route because the drug is injected directly into the bloodstream, bypassing many physiologic barriers, the hostile environment of the gastrointestinal tract, and drug-metabolizing enzymes that are encountered during oral absorption of a drug. Others are all characteristics of oral administration.

DIF: Comprehension REF: Routes of Administration and Dose Forms (Routes of Administration [Oral Route]) | p. 19 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 34. Which organ is involved in the first-pass effect after oral administration of a drug? a. Kidney b. Lungs c. Liver d. Spleen ANS: C

On oral administration, drugs are absorbed and are carried via the portal circulation to the liver, where a percentage of the drug may be metabolized before entering the systemic circulation. After oral dosing, drugs reach the kidney, lungs, and spleen after passing through the liver.

DIF: Comprehension REF: Pharmacokinetics (Metabolism (Biotransformation) [First-Pass Effect]) | p. 16 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 35. Which of the following routes of drug administration produces the most rapid drug response? a. Intravenous b. Intramuscular c. Subcutaneous d. Intradermal ANS: A

Intravenous administration produces the most rapid drug response, with an almost immediate onset of action. Because the injection is made directly into the blood, the absorption phase is bypassed. The intramuscular route, subcutaneous route, and intradermal route all have slower drug response rates than intravenous drug administration.

DIF: Recall REF: Routes of Administration and Dose Forms (Routes of Administration [Intravenous Route]) | p. 20 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 36. What route is used to administer the tuberculosis skin test? a. Intramuscular b. Intradermal c. Intravenous d. Subcutaneous ANS: B

Intradermal administration is used to provide local, rather than systemic, action. Local anesthetics are also given this way. The other routes are all chosen when systemic action is desired. Intramuscular, intradermal, and subcutaneous routes of administration are not used to administer the tuberculosis skin test.

DIF: Recall REF: Routes of Administration and Dose Forms (Routes of Administration [Intradermal Route]) | p. 22 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 37. What type of administration involves the injection of solutions into the spinal subarachnoid space? a. Intrathecal route b. Intraperitoneal route c. Intravenous route d. Intradermal route ANS: A

The intrathecal route is used for injection of solutions into the spinal subarachnoid space.

Intraperitoneal route refers to placing fluids into the peritoneal cavity. Intravenous route refers to administering drugs directly into the blood circulation. Intradermal route refers to injecting a drug just under the skin.

DIF: Recall REF: Routes of Administration and Dose Forms (Routes of Administration [Intrathecal Route]) | p. 22 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 38. Drug preparations may be administered for local or systemic effects. Which is an example of a dose

form used for a local effect? a. Sublingual tablet b. Transdermal patch c. Ophthalmic ointment d. Subcutaneous injection ANS: C

Ophthalmic ointments and drops are used specifically for treating the eye, not for treating a systemic disorder. Administration of a sublingual tablet leads to rapid entry of the drug into the systemic circulation. A transdermal patch is a specialized dose form for the controlled delivery of a drug into the systemic circulation. A subcutaneous injection is applied into the subcutaneous areolar tissue to gain access to the systemic circulation.

DIF: Comprehension REF: Routes of Administration and Dose Forms (Routes of Administration [Topical Route]) | p. 22 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 39. Application of a transdermal patch is an example of parenteral administration because the drug is

delivered in a manner that bypasses the gastrointestinal tract. a. Both parts of the statements are true. b. Both parts of the statements are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: A

Both parts of the statement are true. A transdermal patch is designed to provide continuous controlled release of medication through a semipermeable membrane over a given period after application to the intact skin. Drugs given by the enteral route are placed directly into the gastrointestinal tract by oral or rectal administration. Parenteral means situated or occurring outside of the gastrointestinal tract (intestines). Examples of routes that bypass the gastrointestinal tract include various injection routes, inhalation, and topical administration. In practice, the term parenteral usually refers to an injection.

DIF: Comprehension REF: Routes of Administration and Dose Forms (Routes of Administration) | p. 19 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 40. A patient’s perception that a pill without active ingredients is having a pharmacologic effect is termed a. tachyphylaxis. b. hypersensitivity. c. neurosis.

d. compliance. e. placebo effect.

ANS: E

Placebo effect is the term used to report when a patient perceives a pharmacologic effect after administration of a medication without active ingredients. Tachyphylaxis is a rapid loss of drug sensitivity, akin to tolerance; the other choices are nonsensical answers. Compliance is the ability of a patient to adhere to the instructions of his or her physician.

DIF: Comprehension REF: Factors that Alter Drug Effects | p. 19 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 41. The need for an increasingly larger dose of a drug to obtain the same effects as the original dose is a. drug dependency. b. insufficiency. c. drug tolerance. d. craving.

ANS: C

Tolerance is a phenomenon in which the body changes in some way so that the same dose of drug has a weaker effect over time. Persons who display drug dependency may also display tolerance, but they are two different phenomena. Insufficiency is not a term used to describe the tolerance phenomenon.

Craving, similar to tolerance, may occur alongside drug dependence, but the desire to have more drug is not synonymous with tolerance to a drug’s effects.

DIF: Recall OBJ: 6

REF: Factors that Alter Drug Effects | p. 19 TOP: NBDHE, 6.0. Pharmacology

42. A prodrug is an example of which type mechanism of metabolism? a. Active to active b. Active to inactive c. Inactive to active d. Inactive to inactive ANS: C

An inactive parent drug (prodrug) may be transformed into an active compound. Active to active occurs when an active parent drug is converted to a second active compound, which is then converted to an inactive product. When an active metabolite is formed, the action of the drug is prolonged.

Active to inactive is the most common type of reaction in drug biotransformation. Inactive to inactive is not one of the mechanisms of metabolism. A placebo may be an example.

DIF: Recall OBJ: 3

REF: Pharmacokinetics (Metabolism (Biotransformation)) | p. 16 TOP: NBDHE, 6.0. Pharmacology

43. Which is true of a drug with a stronger affinity for a receptor site versus a drug with a weaker affinity

for the same site? a. A drug with stronger affinity is more potent than a drug with weaker affinity. b. A drug with stronger affinity will function as a competitive antagonist rather than as an agonist.

c. A drug with stronger affinity will function as a competitive antagonist rather than

as an agonist. d. A drug with stronger affinity will function as an agonist.

ANS: A

Drugs with stronger affinity for receptor sites are more potent than drugs with weaker affinities for the same sites. An antagonist counteracts the action of the agonist. There are three types of antagonists: competitive antagonist, noncompetitive antagonist, and physiologic antagonist. An agonist is a drug that has affinity for a receptor, combines with the receptor, and produces an effect.

DIF: Comprehension REF: Mechanism of Action of Drugs (Receptors) | p. 13 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 44. Most drugs are excreted through which mechanism? a. Gastrointestinal tract b. Glomerular filtration c. Active tubular secretion d. Passive tubular diffusion ANS: B

Either the unchanged drug or its metabolites are filtered through the glomeruli and concentrated in the renal tubular fluid. This process depends on the amount of plasma protein binding and the glomerular filtration rate. The gastrointestinal tract is an extrarenal route of excretion, along with the lungs, bile, sweat, saliva, and breast milk. Active secretion transports the drug from the bloodstream across the renal tubular epithelial cells and into the renal tubular fluid. Passive tubular diffusion favors the reabsorption of un-ionized, lipid-soluble compounds.

DIF: Comprehension REF: Pharmacokinetics (Metabolism (Biotransformation) [Excretion]) | p. 17 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 45. The route of administration of a drug affects a. both the onset and duration of response. b. the onset, but not the duration of response. c. the duration, but not the onset of response. d. neither the onset nor the duration of response.

ANS: A

Onset refers to the time required for the drug to begin to have its effect. Duration is the length of a drug’s effect. Both onset and response are affected by the route of administration. The routes of administration may be categorized as enteral when placed in the gastrointestinal tract, or parenteral, which usually means an injection.

DIF: Comprehension REF: Routes of Administration and Dose Forms (Routes of Administration) | p. 19 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 46. How many half-lives of repeated dosing does it take to reach a steady state in the body? a. One b. Two or three

c. Four or five d. Six or seven e. Eight or nine ANS: C

It takes about four or five half-lives of repeated dosing for the level of a drug to build up to a steady state in the body. It takes approximately four to five half-lives for a drug to reach a steady state or to be considered eliminated from the body.

DIF: Recall OBJ: 5

REF: Clinical Pharmacokinetics (Half-Life) | p. 18 TOP: NBDHE, 6.0. Pharmacology

47. Which drug is eliminated with zero-order kinetics? a. Probenecid b. Aspirin c. Allopurinol d. Penicillin e. Naproxyn sodium ANS: B

A few drugs, such as aspirin and alcohol, exhibit zero-order kinetics. The enzymes that metabolize these drugs can become saturated at usual therapeutic doses. Small changes in the dosage of these drugs may produce a large change in concentration in blood serum. There are few drugs that are eliminated with zero-order kinetics, namely aspirin and alcohol.

DIF: Recall OBJ: 5

REF: Clinical Pharmacokinetics (Kinetics) | p. 18 TOP: NBDHE, 6.0. Pharmacology

48. With zero-order kinetics, the a. same amount of drug is metabolized and eliminated from the body per unit of time

regardless of dose. b. same percentage of drug is metabolized and eliminated from the body per unit of

time. c. drug is irreversibly bound to receptor sites. d. drug is not bound to receptor sites.

ANS: A

With high doses, the metabolism of the drug cannot increase and the duration of action of the drug can be greatly prolonged. Zero-order kinetics occurs because the enzymes that metabolize these drugs can become saturated at usual therapeutic doses. If the dose of the drug is increased, the metabolism cannot increase above its maximum rate.

DIF: Comprehension REF: Clinical Pharmacokinetics (Kinetics) | p. 18 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 49. Tolerance is most closely associated with which category of drug? a. Antibiotics b. Angiotensin receptor blockers c. Nonsteroidal anti-inflammatory drugs d. Opioids

e. Anti-hypertensive drugs ANS: D

Tolerance is associated with sedative-hypnotics and opioids. Tolerance is associated with narcotics.

DIF: Comprehension REF: Factors that Alter Drug Effects | p. 19 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Which of the following statements are true regarding drug-receptor interactions? (Select all that

apply.) a. Drug receptors appear to consist of many large molecules that exist either on the cell membrane or within the cell itself. b. A specific drug will usually bind with a specific receptor in a lock-and-key fashion. c. Only a single receptor type is found at the site of action. d. The energy formed by a drug-receptor interaction is very strong and the bond is difficult to break.

ANS: A, B

Drug receptors may exist either on the cell membrane or within the cell. Usually, a specific drug will bind with a specific receptor. More than one receptor type or identical receptors can be found at the site of action. Many drug-receptor interactions consist of weak chemical bonds, and the energy formed during the interaction is very low. As a result, the bonds can be formed and broken easily. Once a bond is broken, another drug molecule immediately binds to the receptor.

DIF: Comprehension REF: Mechanism of Action of Drugs (Receptors) | p. 13 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. A prodrug is an inactive drug compound that becomes transformed into an active drug compound.

ANS: T

This statement represents an example of drug metabolism (converting a drug from inactive to active).

DIF: Recall OBJ: 3

REF: Pharmacokinetics (Metabolism (Biotransformation)) | p. 16 TOP: NBDHE, 6.0. Pharmacology

2. Drugs, after undergoing phase I drug metabolism, are more likely to be distributed to fat tissue.

ANS: F

Phase I drug metabolism usually makes a drug more polar and with less affinity for fatty tissue.

DIF: Recall OBJ: 3

REF: Pharmacokinetics (Metabolism (Biotransformation)) | p. 16 TOP: NBDHE, 6.0. Pharmacology

3. If a drug is a weak base that is excreted via the kidneys, then acidifying the urine will enhance its

excretion.

ANS: T

Weak bases will become ionized in an acid environment and will not be able to passively diffuse out of the kidney tubule.

DIF: Recall OBJ: 4

REF: Pharmacokinetics (Metabolism (Biotransformation) [Excretion]) | p. 17 TOP: NBDHE, 6.0. Pharmacology

4. The route of administration of a drug affects both the onset and duration of response.

ANS: T

Onset refers to the time required the drug to begin to have its effect. Duration is the length of a drug’s effect.

DIF: Recall REF: Routes of Administration and Dose Forms (Routes of Administration) | p. 19 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology

Chapter 03: Adverse Reactions Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. A genetically related abnormal drug response is called a(n) a. toxic reaction. b. idiosyncratic reaction. c. side effect. d. drug allergy.

ANS: B

An idiosyncratic reaction is a genetically related abnormal drug response. A toxic reaction is an adverse drug reaction that is an extension of the pharmacologic effect of the drug. Side effects are dose-related effects on nontarget organs. Drug allergy refers to the interaction of the immune system with the drug. None of these incorrect choices are limited to describing abnormal or genetically related responses.

DIF: Recall OBJ: 1

REF: Definitions and Classifications | p. 24 TOP: NBDHE, 6.0. Pharmacology

2. A drug effect that is neither predictable nor dose related is called a a. therapeutic effect. b. toxic reaction. c. side effect. d. drug allergy. e. Both B and D are correct.

ANS: D

Unlike other adverse reactions, allergic reactions are neither predictable nor dose related. Approved pharmaceuticals are available for use because they produce a predictable and dose-related therapeutic response. Toxic reactions and side effects are dose-related effects, the former on the target organ and the latter on nontarget organs. They might be surprising when they arise, for instance, in patients who are especially sensitive to a drug’s effects. However, they are predictable based on the drug’s doseresponse relationship.

DIF: Recall OBJ: 1

REF: Definitions and Classifications | p. 24 TOP: NBDHE, 6.0. Pharmacology

3. The following choices refer to adverse reactions involving exaggerated effects on target tissues except a. overreaction of a sensitive patient. b. administration of too large a dose. c. caused by a nontherapeutic action of a drug. d. possibly resulting from liver or kidney disease.

ANS: C

This answer is typical of an adverse effect caused by action on nontarget tissues. Exceptional sensitivity to a normal dose and administration of too large a dose for a patient are common actions that lead to exaggerated effect. Liver or kidney disease may reduce metabolism or excretion, respectively.

DIF: Comprehension REF: Clinical Manifestations of Adverse Reactions (Exaggerated Effect on Target Tissues) | p. 25 | Clinical Manifestations of Adverse Reactions (Effect on Nontarget Tissues) | p. 25 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. A dose-related reaction that produces undesirable effects caused by the action on nontarget organs is

called a a. therapeutic effect. b. toxic reaction. c. side effect. d. drug allergy.

ANS: C

A side effect is a predictable, dose-related drug effect that acts on nontarget organs. Therapeutic effect is the desired effect of the drug. Toxic reaction is a predictable, dose-related drug effect that acts on nontarget organs and produces an adverse reaction. In a drug allergy, the immune system of an individual responds to a drug, resulting in an allergic reaction. Drug reactions are not dose related or predictable.

DIF: Comprehension REF: Definitions and Classifications | p. 24 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Immune-complex disease reactions are aggregations of antibodies and a. T lymphocyte cells. b. B lymphocyte cells. c. antigens. d. plasma cells.

ANS: C

Usually there are more antibodies than antigens. When there is a large amount of antigens or the immune system is not clearing antigens, then the antigen:antibody ratio increases. When the number of antibodies is comparable to the amount of antigens then the immune-complex can form. Antigens are proteins against which antibodies are formed. Plasma cells are derived from B-cell lymphocytes.

DIF: Comprehension REF: Clinical Manifestations of Adverse Reactions (Hypersensitivity (Allergic Reaction)) | p. 26 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. The greatest risk to the fetus from exposure to drugs occurs a. just before birth. b. during the third trimester. c. during the second trimester. d. before pregnancy status is known.

ANS: D

Early in pregnancy (first trimester) the organs in the fetus are forming, which is considered the most critical time for teratogenicity. Drugs at these stages may affect the newborn, but the fetus is fully developed. Fetal organogenesis has already occurred; therefore, critical stages in fetal development have passed.

DIF: Recall REF: Clinical Manifestations of Adverse Reactions (Effect on Fetal Development (Teratogenic Effect)) | p. 25 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 7. An acute, life-threatening allergic reaction characterized by hypotension, bronchospasm, laryngeal

edema, and cardiac arrhythmias is what type of hypersensitivity? a. Type I b. Type II c. Type III d. Type IV ANS: A

Type I hypersensitivity, or immediate-type hypersensitivity, is a rapidly produced response targeting the bronchioles, the respiratory system, and the skin. Type II, III, and IV reactions are all slower than type I reactions. Type II hypersensitivity causes cytolytic reactions, such as hemolytic anemia. Type III hypersensitivity is a reaction in which soluble antibody-antigen complexes are formed, causing arthralgia, urticarial skin eruptions, and so forth, with little or no lung involvement. Type IV hypersensitivity, or delayed-type hypersensitivity, is generally manifested as skin eruptions.

DIF: Recall REF: Clinical Manifestations of Adverse Reactions (Hypersensitivity (Allergic Reaction)) | p. 26 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. Which hypersensitivity reaction causes antibody-antigen (immune complex) deposition? a. Type I b. Type II c. Type III d. Type IV

ANS: C

Type III hypersensitivity is a reaction in which soluble antibody-antigen complexes are formed and deposited, causing arthralgia, urticarial skin eruptions, and so forth. Type I hypersensitivity, or immediate-type hypersensitivity, involves drug antigen or allergen binding to immunoglobulin E (IgE) antibodies on inflammatory cells. Type II hypersensitivity causes cytolytic reactions, such as hemolytic anemia. Type IV hypersensitivity, or delayed-type hypersensitivity, generally manifests as skin eruptions.

DIF: Comprehension REF: Clinical Manifestations of Adverse Reactions (Hypersensitivity (Allergic Reaction)) | p. 26 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Which hypersensitivity reaction is termed delayed-type hypersensitivity and is mediated by sensitized

T lymphocytes and macrophages? a. Type I b. Type II c. Type III d. Type IV ANS: D

Type IV hypersensitivity, or delayed-type hypersensitivity, generally manifests as skin eruptions, such as in poison ivy. Type I hypersensitivity, or immediate-type hypersensitivity, involves drug antigen or allergen binding to IgE antibodies on inflammatory cells. Type II hypersensitivity causes cytolytic reactions, such as hemolytic anemia. Type III hypersensitivity is a reaction in which soluble antibodyantigen complexes are formed and deposited, causing arthralgia, urticarial skin eruptions, and so forth.

DIF: Recall REF: Clinical Manifestations of Adverse Reactions (Hypersensitivity (Allergic Reaction)) | p. 27 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 10. Type a. I b. II c. III d. IV

hypersensitivity is mediated by IgE antibodies.

ANS: A

Type I hypersensitivity, or immediate-type hypersensitivity, involves drug antigen or allergen binding to IgE antibodies on inflammatory cells. Type II hypersensitivity causes cytolytic reactions, such as hemolytic anemia. Type III hypersensitivity is a reaction in which soluble antibody-antigen complexes are formed and deposited, causing arthralgia, urticarial skin eruptions, and so forth. Type IV hypersensitivity, or delayed-type hypersensitivity, generally manifests as skin eruptions, such as in poison ivy.

DIF: Recall REF: Clinical Manifestations of Adverse Reactions (Hypersensitivity (Allergic Reaction)) | p. 26 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

11. Approximately 10% of male African Americans develop a severe hemolytic anemia when given the

antimalarial drug primaquine. Such a response is categorized as a(n) a. idiosyncratic reaction. b. drug side effect. c. genetically determined abnormal reaction. d. allergic reaction. e. Both A and C are correct.

ANS: E

Primaquine-induced hemolytic anemia is a genetically determined abnormal reaction, also known as a drug idiosyncrasy. Idiosyncratic reactions are not drug side effects; they are genetically related abnormal drug responses. Idiosyncratic reactions might involve an immune mechanism but are not considered allergic responses, such as type I through type IV hypersensitivity reactions.

DIF: Comprehension REF: Clinical Manifestations of Adverse Reactions (Idiosyncrasy) | p. 27 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 12. A dose of a drug that kills 50% of experimental animals is termed a. ED50. b. minimally effective dose. c. LD50. d. therapeutic index.

ANS: C

By definition, the LD50 is the median lethal dose, that is, a dose level that leads to death in 50% of the animals tested. ED50 is the median effective dose, a dose that produces a therapeutic effect in 50% of the subjects tested. A minimally effective dose should not cause death unless death is the desired endpoint. In this case, the incidence of death should be lower to be designated minimal. The therapeutic index is the ratio of LD50 to ED50.

DIF: Recall OBJ: 3

REF: Toxicologic Evaluation of Drugs | pp. 27-28 TOP: NBDHE, 6.0. Pharmacology

13. In an assessment of drug action for a certain therapeutic agent, results indicate that the ED50 is 3

mg/kg, and the LD50 is 300 mg/kg. What is the therapeutic index for this agent? a. 3 b. 300 c. 0.01 d. 100 ANS: D

If the value of the TI is small, then toxicity is more likely. If the TI is large, then the drug will be safer.

A drug with a wide TI will have a large LD50 and a small ED50 (the distance between these curves is large). A TI of greater than 10 is usually needed to produce a therapeutically useful drug. One must divide the LD50 value by the ED50 value. The LD50 value (300) divided by the ED50 value (3) equals 100.

DIF: Application OBJ: 3

REF: Toxicologic Evaluation of Drugs | p. 28 TOP: NBDHE, 6.0. Pharmacology

14. Although drug A and drug B have the same ED50, drug B has a wider therapeutic index (TI); therefore,

drug A has a greater LD50 than drug B. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Drug B has a wider therapeutic index. This means that drug B must be safer than drug A and that the amount of drug needed to be lethal to 50% of test animals must be greater for drug B than for drug A. Therefore, drug B has a greater LD50 than drug A. The therapeutic index is the ratio of the LD 50 to ED50. A wide therapeutic index means a greater difference between the LD 50 and the ED50 and therefore a greater ratio. If drug B has a wider therapeutic index than drug A and the two drugs have an equivalent ED50, then the LD50 of drug B must be greater.

DIF: Application OBJ: 3

REF: Toxicologic Evaluation of Drugs | p. 28 TOP: NBDHE, 6.0. Pharmacology

15. Which of the following is the recommended solution for the adverse effect of nausea following

administration of a drug? a. Cease taking the drug. b. Go outside and get some fresh air. c. Take the drug with food or milk. d. Take the drug at bedtime. e. Seek medical attention.

ANS: C

Nausea can usually be alleviated by taking the drug with food or milk. It is important to continue taking drugs as prescribed unless the patient has consulted with the prescriber. Some adverse effects, such as headache or upset stomach, normally do not require medical attention. Sedation can be minimized by taking the drug at bedtime. Other adverse effects require medical attention.

DIF: Comprehension REF: Recognizing Adverse Drug Effects | p. 28 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 16. What should the dental hygienist do first if a patient reports a suspected adverse drug effect? a. Administer epinephrine. b. Determine what drugs the patient is taking. c. Have that patient drink a sugary liquid such as apple juice. d. Call 9-1-1. e. Drive the patient to the nearest hospital emergency room.

ANS: B

Determine what drugs the patient is taking. Once a list of drugs is identified, it is important to determine which drug or drugs may be causing the adverse effect. If the patient is taking multiple drugs the dental hygienist should determine when the patient is taking each drug. Also, determine whether or not the symptoms of the adverse effect occurred after beginning drug therapy and how long after the patient took the drug. Epinephrine is administered for anaphylaxis. Drugs used in dentistry that can produce anaphylaxis include the penicillins, ester local anesthetics, and aspirin. Drinking a sugary liquid is useful for a patient with hypoglycemia. Calling 9-1-1 is useful for a severe allergic reaction or heart attack; however, a drug allergy accounts for less than 5% of all adverse reactions. It is better to call emergency medical services (EMS) if transportation to the hospital is required as there are liability issues with driving the patient to the hospital.

DIF: Comprehension REF: Recognizing Adverse Drug Effects | p. 28 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 17. Which will block the action of histamine during an allergic reaction? a. Macrolide b. Epinephrine c. Anticonvulsants d. Benzodiazepines ANS: B

Epinephrine blocks the action of histamine during an allergic reaction. Macrolides will not block the action of histamine; however, they will raise the plasma levels of many drugs. Anticonvulsants do not block the action of histamine, although they can increase or decrease the metabolism of many drugs and each other, leading to either increased or decreased plasma levels of these drugs. Benzodiazepines and first-generation antihistamines will increase the level of sedation, but will not block the action of histamine.

DIF: Recall REF: Clinical Manifestations of Adverse Reactions (Drug Interactions [Table 3.1: Selected Drug Interactions]) | p. 26 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 18. Which is safe to administer to a pregnant patient? a. Tetracycline b. NSAIDs c. Penicillin d. Benzodiazepines ANS: C

Penicillin and erythromycin, acetaminophen, and lidocaine are considered to be among the safest; however, even these drugs should be administered only if there is clear need. Tetracycline, NSAIDs, and the benzodiazepines are examples of drugs used in dentistry that are contraindicated during pregnancy.

DIF: Comprehension REF: Clinical Manifestations of Adverse Reactions (Effect on Fetal Development (Teratogenic Effect)) | p. 25 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 19. Which is least likely to be a true allergic reaction? a. Urticaria

b. Rash c. Anaphylaxis d. Dyspepsia ANS: D

Drugs taken orally can produce gastrointestinal symptoms, such as nausea or dyspepsia, because of their local actions on the gastrointestinal tract. A drug allergy is an immunologic response to a drug resulting in a reaction such as rash or anaphylaxis. The targets of this reaction are the bronchioles, resulting in anaphylactic shock; the respiratory system, resulting in rhinitis and asthma; and the skin, resulting in urticaria and dermatitis.

DIF: Comprehension REF: Clinical Manifestations of Adverse Reactions (Local Effect) | p. 25 | Clinical Manifestations of Adverse Reactions (Hypersensitivity (Allergic Reaction)) | p. 26 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Drug allergy and a side effect are two examples of dose-related responses.

ANS: F

A side effect of a drug may be dose related, but drug allergy is neither predictable nor dose related.

DIF: Recall OBJ: 1

REF: Definitions and Classifications | p. 24 TOP: NBDHE, 6.0. Pharmacology

2. Tetracycline, nonsteroidal antiinflammatory drugs (NSAIDs), and the benzodiazepines are safe to

administer to a pregnant patient.

ANS: F

Tetracycline, NSAIDs, and the benzodiazepines are examples of drugs used in dentistry that are contraindicated during pregnancy.

DIF: Recall REF: Clinical Manifestations of Adverse Reactions (Effect on Fetal Development (Teratogenic Effect)) | p. 25 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 3. The greater the therapeutic index is, the greater the toxicity will be.

ANS: F

The therapeutic index is the ratio of the LD50 to ED50. The smaller the ratio is, the closer the LD50 is to the ED50 and therefore the closer a deadly dose is to the therapeutic dose. Consequently, the lesser the therapeutic index is, the greater the toxicity will be.

DIF: Recall OBJ: 3

REF: Toxicologic Evaluation of Drugs | p. 28 TOP: NBDHE, 6.0. Pharmacology

Chapter 04: Autonomic Drugs Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition

MULTIPLE CHOICE 1. The autonomic nervous system (ANS) functions as a(n) a. somatic negative feedback b. somatic modulating c. automatic negative feedback d. automatic modulating

system for many bodily functions.

ANS: D

The ANS functions largely as an automatic modulating system for many bodily functions, including the regulation of blood pressure and heart rate, gastrointestinal tract motility, salivary gland secretions, and bronchial smooth muscle. Autonomic means that the system functions automatically without conscious thought, in contrast to somatic, which is voluntary or willful. The system modulates body functions because, in general, the divisions of the ANS tend to act in opposite directions.

DIF: Recall REF: Autonomic Nervous System | p. 31 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. In the autonomic nervous system (ANS), the target organ is innervated by the a. preganglionic afferent b. preganglionic efferent c. postganglionic afferent d. postganglionic efferent

neuron.

ANS: D

The target organ is innervated by the postganglionic efferent neuron. The preganglionic neuron originates in the central nervous system (CNS) and passes out to form the ganglia at the synapse with the postganglionic neuron. The postganglionic neuron originates in the ganglia and innervates the effector organ or tissue. The preganglionic nerve fiber originates in the brain. It ends at the synapse, where the neurotransmitter carries the message to the postganglionic fiber. Afferent fibers are sensory and efferent fibers are motor.

DIF: Comprehension REF: Autonomic Nervous System (Anatomy) | p. 31 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. The parasympathetic fibers originate in the nuclei of the a. sacral and lumbar b. cranial nerves and sacral c. cranial nerves and lumbar d. thoracic and lumbar e. None of the above are correct

segments of the spinal cord.

ANS: B

Preganglionic fibers of the parasympathetic division originate in the nuclei of the third, seventh, ninth, and tenth cranial nerves, as well as the second through the fourth sacral segments of the spinal cord.

Preganglionic fibers of the sympathetic division span from the thoracic and lumbar portion of the spinal cord.

DIF: Comprehension REF: Autonomic Nervous System (Parasympathetic Autonomic Nervous System) | p. 31 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. The anatomy of what system contains long preganglionic nerves and short postganglionic nerves? a. Parasympathetic autonomic b. Sympathetic autonomic c. Somatic d. Sensory afferent ANS: A

The parasympathetic nerves travel and terminate at the ganglia that are close to the organs they are innervating. Sympathetic preganglionic neurons terminate close to the spinal cord and synapse with long postganglionic fibers. Somatic and sensory afferent systems do not have ganglia.

DIF: Comprehension REF: Autonomic Nervous System (Parasympathetic Autonomic Nervous System) | p. 31 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Which of the following statements is true concerning the organization of the sympathetic division of

the autonomic nervous system (SANS)? a. The cell bodies that give origin to the postganglionic fibers of the SANS span from the thoracic (T1) to the lumbar (L2) portion of the spinal cord. b. The preganglionic fibers exit the spinal column to enter the sympathetic chain located along each side of the vertebral column. c. Once a part of the sympathetic chain, preganglionic fibers form a single synaptic connection, with postganglionic cell bodies located up and down the sympathetic chain. d. Stimulation of the SANS produces a more targeted effect than stimulation of the parasympathetic division of the autonomic nervous system (PANS).

ANS: B

Preganglionic fibers of the SANS exit the spinal column to enter the sympathetic chain located along each side of the vertebral column. The cell bodies that give origin to the preganglionic fibers of the SANS span from the thoracic (T1) to the lumbar (L2) portion of the spinal cord. Once a part of the sympathetic chain, preganglionic fibers form multiple synaptic connections with postganglionic cell bodies located up and down the sympathetic chain. Stimulation of the SANS produces a more diffuse effect than stimulation of the PANS. DIF: Comprehension REF: Autonomic Nervous System (Sympathetic Autonomic Nervous System) | pp. 31-32 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 6. When the SANS is stimulated, the adrenal

circulation. a. cortex; epinephrine b. cortex; acetylcholine c. medulla; epinephrine d. medulla; acetylcholine

releases primarily

into the systemic

ANS: C

The adrenal medulla releases primarily epinephrine and a small amount of norepinephrine into the systemic circulation. Thus epinephrine is the neurotransmitter of the postganglionic neuron of the SANS. The adrenal glands are endocrine glands that are found at the superior pole of each kidney.

Each gland contains an outer cortex and inner medulla. The adrenal medulla serves as a sympathetic ganglion and secretes catecholamines, mainly epinephrine, while the adrenal cortex secretes several steroid hormones with multiple actions.

DIF: Comprehension REF: Autonomic Nervous System (Sympathetic Autonomic Nervous System) | p. 32 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 7. Which of the following choices would occur during a generalized discharge of the sympathetic

nervous system? a. Diarrhea b. Urination c. Glycogen breakdown d. Miosis e. None of the above ANS: C

The sympathetic system makes additional energy available for fight or flight. Diarrhea, urination, and miosis are all effects of stimulation of the parasympathetic nervous system.

DIF: Application REF: Autonomic Nervous System (Functional Organization [Table 4.1: Effects of the Autonomic Nervous System on Effector Organs]) | p. 33 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 8. Which of the following statements is true concerning the organization of the autonomic nervous

system (ANS)? a. All body tissues are innervated by the ANS. b. All organs receive both parasympathetic and sympathetic innervation. c. If a tissue receives both innervations, the response will be equal to the sum of excitatory and inhibitory influences of the two divisions of the ANS. d. Sensory fibers in one division cannot influence the motor fibers in the other.

ANS: C

The response will be equal to the sum of excitatory and inhibitory influences of the two divisions of the ANS, known as modulation. Almost all body tissues are innervated by the ANS, with many, but not all, organs receiving both parasympathetic and sympathetic innervation. Sensory fibers in one division can influence the motor fibers in the other.

DIF: Recall OBJ: 1

REF: Autonomic Nervous System (Functional Organization) | p. 32 TOP: NBDHE, 6.0. Pharmacology

9. The neurotransmitter released from a preganglionic neuron in the sympathetic division of the

autonomic nervous system (ANS) is a. epinephrine. b. norepinephrine.

c. dopamine. d. acetylcholine.

ANS: D

The neurotransmitter released from all autonomic preganglionic neurons is acetylcholine. Epinephrine is released from the adrenal medulla. Norepinephrine is released from postganglionic sympathetic neurons. Dopamine is not a transmitter of the ANS. DIF: Recall OBJ: 1

REF: Autonomic Nervous System (Neurotransmitters) | p. 33 TOP: NBDHE, 6.0. Pharmacology

10. Which of the following substances will block the action of acetylcholine at the postganglionic endings

in the parasympathetic autonomic nervous system (PANS)? a. Atropine b. Curare c. Hexamethonium d. Acetic acid ANS: A

Atropine will block the action of acetylcholine at the postganglionic endings in the PANS. Differences exist among receptors that have acetylcholine as a neurotransmitter—subtypes of acetylcholineinnervated receptors that are located in anatomically different synapses. Curare blocks the response of skeletal muscle to acetylcholine but does not block its effect on tissues such as the salivary gland.

Hexamethonium blocks the action of acetylcholine at the ganglia.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Adverse Reactions]) | p. 36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 11. Which of the following statements is true concerning direct- and indirect-acting cholinergic agents? a. A direct agent causes release of neurotransmitter and an indirect agent acts on the

receptor. b. The indirect-acting agents include the choline derivatives and pilocarpine. c. The indirect-acting cholinesterase inhibitors act by stimulating release of acetylcholine. d. Inhibiting the enzyme that normally destroys acetylcholine results in stimulation of the PANS. ANS: D

When the enzyme that normally destroys acetylcholine is inhibited, the concentration of acetylcholine builds up, resulting in PANS stimulation. A direct agent acts on the receptor, and an indirect agent causes release of the neurotransmitter. The direct-acting agents include the choline derivatives and pilocarpine. The indirect-acting cholinesterase inhibitors act by inhibiting the enzyme cholinesterase.

DIF: Application REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents) | p. 35 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 12. The direct effect of acetylcholine on the heart is _ a. negative; negative

chronotropic and _

inotropic action.

b. c. d. e.

positive; positive negative; positive positive; negative None of the above are correct

ANS: A

Acetylcholine produces a negative chronotropic (reduced rate) and negative inotropic (force) of heart contraction. Cholinergic agents are classified as direct acting (acts on receptor) or indirect acting (causes release of neurotransmitter). The direct-acting agents include the choline derivatives and pilocarpine. The choline derivatives include both acetylcholine and other, more stable choline derivatives. A decrease in cardiac output is associated with these agents.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Pharmacologic Effects]) | p. 35 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. Which of the following is true concerning the pharmacologic effects associated with cholinergic

agents? a. Tachycardia and an increase in blood pressure and cardiac output b. Stasis of intestinal motility c. Miosis d. An increase in intraocular pressure ANS: C

Cholinergic agents produce miosis and cause cycloplegia. Cycloplegia is a paralysis of the ciliary muscles of the eye that results in loss of visual accommodation. Generally, bradycardia and a decrease in blood pressure and cardiac output occur. Cholinergic agents excite the smooth muscle of the gastrointestinal tract, producing an increase in activity, motility, and secretion. These agents decrease intraocular pressure, and are useful in the treatment of glaucoma.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Pharmacologic Effects]) | p. 35 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 14. The acronym SLUD denotes adverse reactions associated with administration of a. cholinergic b. anticholinergic c. adrenergic d. antiadrenergic

agents.

ANS: A

SLUD (salivation, lacrimation, urination, and defecation) is associated with administration of cholinergic agents. These adverse reactions are essentially extensions of their pharmacologic effects.

Acetylcholine is the principal neurotransmitter of the parasympathetic autonomic nervous system (PANS). Norepinephrine (NE) and epinephrine are the major neurotransmitters of the sympathetic autonomic nervous system (SANS). In general, the two divisions of the autonomic nervous system (ANS) tend to act in opposite directions. Cholinergic stimulation is most like antiadrenergic stimulation and the opposite of adrenergic and anticholinergic stimulation.

DIF: Comprehension

REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Adverse Reactions]) | p. 36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 15. The S in SLUD stands for a. sympathetic. b. salivation. c. severe. d. secretion.

ANS: B

SLUD is the acronym used to describe the toxic effects noted when large doses of cholinergic agents are ingested. With even larger doses, neuromuscular paralysis can occur as a result of the effect on the neuromuscular junction. CNS effects, such as confusion, can be seen if toxic doses are administered.

The S in SLUD stands for salivation, the L stands for lacrimation (or tearing), the U stands for urination, and the D for defecation.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Adverse Reactions]) | p. 36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 16. A combination of pralidoxime and atropine is used to treat an overdose of a. acetylcholine b. cholinesterase c. epinephrine d. norepinephrine

inhibitors.

ANS: B

Pralidoxime (2-PAM, Protopam) and atropine may be used to treat an overdose of cholinesterase inhibitors, such as the insecticides or organophosphates (parathion). The action of acetylcholine is terminated by hydrolysis by acetylcholinesterase to yield the inactive metabolites choline and acetic acid. Pralidoxime regenerates the irreversibly bound acetylcholine receptor sites that are bound by the inhibitors, and atropine blocks the muscarinic effects of the excess acetylcholine present. Epinephrine and norepinephrine are the major neurotransmitters of the sympathetic autonomic nervous system (SANS).

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Adverse Reactions]) | p. 36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 17. Which of the following agents is used in the treatment of an overdose of acetylcholinesterase

inhibitors? a. Malathion b. Epinephrine c. Pralidoxime d. Physostigmine ANS: C

Pralidoxime regenerates irreversibly bound acetylcholinesterase enzymes that had been inactivated by covalently bound acetylcholinesterase inhibitors. Malathion and physostigmine are acetylcholinesterase inhibitors. Epinephrine is a sympathomimetic.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Adverse Reactions]) | p. 36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 18. Which of the following conditions is not a relative contraindication or caution with the use of

cholinergic agents? a. Bronchial asthma b. Hypothyroidism c. Myasthenia gravis treated with neostigmine d. Peptic ulcer ANS: B

Hypothyroidism is not a relative contraindication or caution with the use of cholinergic agents; however, hyperthyroidism is because it may cause an increased risk of atrial fibrillation. Bronchial asthma, hyperthyroidism, gastrointestinal tract or urinary tract obstruction, severe cardiac disease, myasthenia gravis treated with neostigmine, and peptic ulcer all represent relative contraindications to or cautions with the use of cholinergic agents.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Contraindications]) | p. 36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 19. The primary objective of cholinergic drug therapy in the treatment of glaucoma is a. increasing the convexity of the lens. b. dilating the vessels of the eye. c. dilating the pupil. d. reducing intraocular pressure. e. inhibiting cholinesterase.

ANS: D

The cholinergic agents reduce intraocular pressure, produce miosis, and cause cycloplegia. Pilocarpine is an example of a direct-acting cholinergic agent that is used to treat glaucoma. Cycloplegia is a paralysis of the ciliary muscles of the eye that results in loss of visual accommodation. Glaucoma is a disease characterized by increased intraocular pressure. Blindness may result if the high pressure persists. The main object of drug therapy with cholinergic agents is to reduce that pressure.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Pharmacologic Effects]) | p. 35 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 20. Which drug would be best to treat xerostomia? a. Atropine b. Propranolol c. Pilocarpine d. Pseudoephedrine ANS: C

Xerostomia is best treated with a cholinergic agent such as pilocarpine, and it is prescribed for this condition. Its success may be limited because of the myriad of potential side effects. Common side effects from pilocarpine include perspiration, nausea, rhinitis, chills, and flushing. Atropine causes xerostomia. Propranolol is -adrenergic blocker. Pseudoephedrine is an adrenergic agonist, which often decreases secretions.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Uses]) | p.

36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 21. Neostigmine is an indirect-acting cholinergic agent that is classified as (1) indirect acting and (2)

irreversible. a. Both claims are true. b. Claim 1 is true; claim 2 is false. c. Claim 1 is false; claim 2 is true. d. Neither claim 1 nor claim 2 is true.

ANS: B

The cholinesterase inhibitors are divided into groups based on the degree of reversibility with which they are bound to the enzyme. Edrophonium is rapidly reversible, whereas physostigmine and neostigmine are slowly reversible. These agents are used to treat glaucoma and myasthenia gravis.

Neostigmine is a cholinergic agent that is indirect acting and reversible.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Uses]) | p.

36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 22. Sarin was used on a subway in Japan to poison riders. Sarin is a(n) a. sympathomimetic. b. anticholinergic. c. anticholinesterase. d. sympatholytic.

ANS: C

Sarin inhibits the action of acetylcholinesterase, inhibiting the breakdown of acetylcholine. Sarin leads to stimulation of the cholinergic receptors, not antagonism, and it is not classified as a sympathomimetic or a sympatholytic.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Uses]) | p.

37 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 23. Anticholinergic agents prevent the action of acetylcholine at the a. preganglionic sympathetic b. postganglionic parasympathetic c. preganglionic sympathetic d. postganglionic parasympathetic ANS: D

endings.

The anticholinergic drugs block the action of acetylcholine postganglionic parasympathetic targets such as smooth muscles, glandular tissue, and the heart. These agents are called antimuscarinic agents because they block the muscarinic receptors and not the nicotinic receptors. The anticholinergic agents prevent the action of acetylcholine at the postganglionic parasympathetic endings. The release of acetylcholine is not prevented, but the receptor site is competitively blocked by the anticholinergics.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 24. Tertiary anticholinergic agents are a. lipid soluble; easily b. lipid soluble; do not c. not lipid soluble; easily d. not lipid soluble; do not

soluble and

penetrate the brain.

ANS: A

Atropine and scopolamine are tertiary agents. Propantheline and glycopyrrolate are quaternary agents.

Because of their water solubility, quaternary agents do not penetrate the CNS well. The quaternary agents have fewer CNS effects because they are less likely than other agents to enter the brain. Tertiary agents are lipid soluble and can easily penetrate the brain.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Pharmacologic Effects]) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 25. Ipratropium is a(n) a. cholinergic b. anticholinergic c. adrenergic d. antiadrenergic

_ found in an inhaler used to treat asthma.

ANS: B

Anticholinergics relax smooth muscle in the respiratory and gastrointestinal tracts. Relaxation of smooth muscle in the respiratory tract causes bronchial dilation. Ipratropium is an anticholinergic. A beta-2 adrenergic effect causes a relaxation of bronchiole smooth muscle. Due to the largely opposite actions of the divisions of the autonomic nervous system, an anticholinergic drug will function much like an adrenergic drug and will have a similar effect on bronchiolar smooth muscle.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Pharmacologic Effects]) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 26. Anticholinergics a. accelerate gastric emptying. b. decrease esophageal and gastric motility. c. cause miosis. d. do not have an effect on heart rate.

ANS: B

Anticholinergics decrease esophageal and gastric motility. The effect of anticholinergics on gastrointestinal motility has given rise to the name spasmolytic agents. If these drugs are used repeatedly, constipation can result. Anticholinergics delay gastric emptying. Parasympatholytics paralyze the ciliary muscles of the eye, resulting in a loss of accommodation. Bradycardia predominates with small doses of anticholinergic agents; however, tachycardia predominates with large doses because the anticholinergic agents can produce vagal blockade.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Pharmacologic Effects]) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27. Which of the following choices represents potential cardiac effects of anticholinergic agents? a. Bradycardia exclusively b. Tachycardia exclusively c. Variable; bradycardia predominates with small doses and tachycardia with large

doses d. No cardiac effect from the use of these agents ANS: C

This variable response in the heart rate occurs because heart rate is a function of both direct and indirect effects. This effect has been used therapeutically to prevent cardiac slowing during general anesthesia. Bradycardia predominates with small doses; however, with large therapeutic doses, the anticholinergic agents can produce vagal blockade, resulting in tachycardia.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Pharmacologic Effects]) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 28. A drug with anticholinergic side effects might exhibit all of the following except a. mydriasis. b. increased salivation. c. tachycardia. d. constipation.

ANS: B

Cholinergic agents increase secretions, such as salivation, and anticholinergics prevent this action.

Mydriasis, tachycardia, and constipation are all characteristic effects of antagonizing the cholinergic system, which anticholinergics do.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Pharmacologic Effects]) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 29. Which of the following categories of autonomic nervous system (ANS) agents can cause an acute rise

in intraocular blood pressure in patients with narrow-angle glaucoma? a. Cholinergic b. Anticholinergic c. Adrenergic d. Antiadrenergic

ANS: B

Anticholinergics are the only ANS drug group that can cause an acute rise in intraocular pressure in patients with narrow-angle glaucoma. Glaucoma is divided into narrow-angle (5% of glaucoma cases) and open-angle glaucoma (95% of glaucoma cases). Anticholinergic drugs can precipitate an acute attack in unrecognized cases of this rare condition.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Contraindications]) | p. 38 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 30. Indications for the use of anticholinergic agents include a. stimulation of salivary secretion for xerostomic patients. b. treatment of gastrointestinal disorders associated with decreased motility. c. treatment in combination with levodopa for patients with Parkinson disease. d. use as an antipsychotic.

ANS: C

At present, anticholinergic agents are used occasionally in combination with levodopa for the treatment of Parkinson disease. Before the introduction of levodopa, anticholinergic agents were commonly used to reduce the tremors and rigidity associated with Parkinson disease. Patients treated with these agents predictably experienced the side effects of dry mouth and blurred vision.

Anticholinergic agents inhibit the secretions of saliva and bronchial mucus that can be stimulated by general anesthesia. Many types of gastrointestinal disorders associated with increased motility or acid secretion have been treated with anticholinergic agents. Anticholinergic agents, such as trihexyphenidyl and benztropine, are often administered concurrently with the phenothiazines to reduce rigidity and tremor; however, anticholinergics themselves are not antipsychotic medications.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Contraindications]) | p. 38 | Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Uses]) | p. 38 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 31. Which of the following is a catecholamine? a. Isoproterenol b. Norepinephrine c. Epinephrine d. Both B and C e. All of the above ANS: E

The term catecholamine is made up of two terms that relate to their structure. Catechol refers to 1,2dihydroxybenzene. Amine refers to the chemical structure –NH2. Norepinephrine, epinephrine, and dopamine are endogenous sympathetic neurotransmitters that are catecholamines. Isoproterenol (Isuprel) is an exogenous catecholamine.

DIF: Comprehension REF: Sympathetic Autonomic Nervous System | p. 39 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 32. Which of the following agents is an indirect-acting sympathetic agonist?

a. b. c. d. e.

Albuterol Pseudoephedrine Amphetamine Physostigmine Epinephrine

ANS: C

Indirect sympathetic agonist agents, such as amphetamine, release endogenous norepinephrine, which then produces a response. Albuterol and epinephrine are direct-acting sympathetic agonists.

Pseudoephedrine is a mixed agonist that can either stimulate the receptor directly or release endogenous norepinephrine to cause a response. Physostigmine is not a sympathetic agent.

DIF: Comprehension REF: Sympathetic Autonomic Nervous System | p. 39 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 33. Which of the following agents is known to deplete endogenous norepinephrine? a. Propranolol b. Reserpine c. Phentolamine d. Yohimbine e. None of the above ANS: B

Reserpine reduces sympathetic neurotransmission by entering the nerve terminal and disrupting storage of norepinephrine. Propranolol is a -adrenergic receptor blocker; phentolamine and yohimbine are -adrenergic receptor blockers.

DIF: Recall OBJ: 4

REF: Sympathetic Autonomic Nervous System | p. 39 TOP: NBDHE, 6.0. Pharmacology

34. The action of norepinephrine is terminated by which of the following choices? a. Uptake into the presynaptic nerve terminal by an amine-specific pump b. Action of catechol-O-methyltransferase (COMT) c. Action of monoamine oxidase (MAO) d. All of the above e. None of the above ANS: D

The action of norepinephrine can be terminated by any of the above mechanisms. The action of norepinephrine is terminated primarily by reuptake into the presynaptic nerve terminal by an aminespecific pump. In addition, two enzyme systems, MAO and COMT, are involved in the breakdown of a portion of both epinephrine and norepinephrine.

DIF: Application OBJ: 4

REF: Sympathetic Autonomic Nervous System | p. 39 TOP: NBDHE, 6.0. Pharmacology

35. The stimulation of -Adrenergic receptors causes a. vasoconstriction. b. vasodilation. c. tachycardia.

d. miosis.

ANS: A

-Adrenergic receptors are found on blood vessels and stimulation of them causes vasoconstriction. Adrenergic agonists cause vasoconstriction and mydriasis. -adrenergic agonists, but not -adrenergic agonists, cause tachycardia.

DIF: Recall REF: Sympathetic Autonomic Nervous System (Sympathetic Autonomic Nervous System Receptors [AlphaReceptors]) | p. 39 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 36. Stimulation of 2-Adrenergic receptors results in a. vasoconstriction of skin and skeletal muscle. b. increase in heart rate and force of contraction. c. smooth-muscle relaxation. d. bronchoconstriction.

ANS: C

The stimulation of 2-receptors results in smooth-muscle relaxation. Because the blood vessels of the skeletal muscle are innervated by 2-receptors, stimulation causes vasodilation. Relaxation of the smooth muscles of the bronchioles, also containing 2-receptors, results in bronchodilation. The stimulation of the -receptors results in smooth-muscle excitation or contraction, which then causes vasoconstriction of skin and skeletal muscle. 1-receptor stimulation excitation causes stimulation of the heart muscle, resulting in a positive chronotropic effect (increased rate) and a positive inotropic effect (increased strength).

DIF: Recall REF: Sympathetic Autonomic Nervous System (Sympathetic Autonomic Nervous System Receptors [BetaReceptors]) | p. 39 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 37. On administration of an agent, heart rate increases because of a direct effect on the heart. However,

total peripheral resistance decreases dramatically. As a consequence, systolic blood pressure increases only slightly, and mean arterial pressure typically falls. This agent is a. epinephrine. b. norepinephrine. c. phenylephrine. d. isoproterenol.

ANS: D

This response is characteristic of a pure -adrenergic agonist, of which isoproterenol is an example.

The primary actions are stimulation of the heart and relaxation of the vessels supplying the skeletal muscles. This leads to tachycardia and decreased peripheral resistance. Epinephrine is a mixed - and -adrenergic agonist. This balance leads to little change or an increase in mean arterial pressure.

Norepinephrine and phenylephrine are á-adrenergic agonists, which constrict blood vessels and lead to a clear rise in mean arterial pressure.

DIF: Application REF: Sympathetic Autonomic Nervous System (Adrenergic (Sympathomimetic) Agents [Pharmacologic Effects]) | p. 40 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology

38. Agents such as albuterol (Proventil, Ventolin) cause bronchodilation by binding to a. alpha b. beta1 c. beta2 d. nicotinic

receptors.

ANS: C

2-Selective receptor agonists such as albuterol (Proventil, Ventolin) and metaproterenol (Alupent) are indicated for the treatment of asthma. Epinephrine is the drug of choice for the treatment of anaphylaxis. Albuterol is a 2-selective receptor agonist.

DIF: Recall REF: Sympathetic Autonomic Nervous System (Adrenergic (Sympathomimetic) Agents [Table 4.5: Examples of Adrenergic Receptor Agonists (Sympathomimetic Adrenergic Agonists)]) | p. 40 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 39. Sympathomimetic agents will stimulate salivary flow from which of the following salivary glands: (1)

parotid, (2) submandibular, (3) sublingual? a. 1, 2, 3 b. 1, 2 c. 1, 3 d. 2, 3 ANS: D

The mucus-secreting cells of the submandibular gland and sublingual gland are stimulated by the sympathomimetic agents to release a small amount of thick, viscous saliva. Because the parotid gland has no sympathetic innervation (only parasympathetic) and the sympathomimetics produce vasoconstriction, the flow of saliva is often reduced, resulting in xerostomia.

DIF: Application REF: Sympathetic Autonomic Nervous System (Adrenergic (Sympathomimetic) Agents [Pharmacologic Effects]) | p. 40 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 40. Sympathomimetic agents should be used with caution in patients with (1) angina, (2) hypertension, (3)

hypothyroidism. a. 1, 2, 3 b. 1, 2 c. 1, 3 d. 2, 3 ANS: B

Sympathomimetic agents should be used with caution in patients with angina, hypertension, and hyperthyroidism. The adverse reactions associated with the adrenergic drugs are extensions of their pharmacologic effects. Anxiety and tremors may occur, and the patient may have palpitations. Serious arrhythmias can result. Agents with -adrenergic action can also cause a dramatic rise in blood pressure. These drugs stimulate - and -receptors in the heart and as such would further increase blood pressure and heart rate in persons with already increased blood pressure and heart rates, which could lead to arrhythmias or a myocardial infarction.

DIF: Comprehension REF: Sympathetic Autonomic Nervous System (Adrenergic (Sympathomimetic) Agents [Adverse Reactions]) | p. 41 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 41. Which of the following sympathomimetic agents is commonly used in dentistry? a. Ephedrine b. Terbutaline c. Dipivefrin d. Levonordefrin ANS: D

Levonordefrin is a derivative of norepinephrine. Although claims made for this drug include less CNS excitation and cardiac stimulation, the dose required to produce vasoconstriction equal to that caused by epinephrine is higher. Levonordefrin is a vasoconstrictor often added to local anesthetic solutions of mepivacaine.

DIF: Recall REF: Sympathetic Autonomic Nervous System (Adrenergic (Sympathomimetic) Agents [Specific Adrenergic Agents]) | p. 41 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 42. Which of the following agents is being used to produce methamphetamine? a. Phenylephrine b. Pseudoephedrine c. Dopamine d. Dipivefrin ANS: B

Pseudoephedrine is present in over-the-counter products designed for the treatment of the common cold or allergies. The newest use of these agents is to “cook” them to produce methamphetamine, which is used illicitly. Because of this use, their availability has been restricted. Phenylephrine is used as a mydriatic and in nose sprays to relieve congestion. Dopamine is a neurotransmitter in parts of the CNS. It is used primarily in the treatment of shock. Dipivefrin and epinephrine are sympathomimetic ophthalmics that are used to treat glaucoma.

DIF: Recall REF: Sympathetic Autonomic Nervous System (Adrenergic (Sympathomimetic) Agents [Specific Adrenergic Agents]) | p. 41 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 43. Patients pretreated with a. cholinergic b. anticholinergic c. -adrenergic d. -adrenergic blocking ANS: D

agents are prone to epinephrine reversal.

The -adrenergic blocking agents competitively inhibit the vasoconstricting effects of the adrenergic agents. This reduces the sympathetic tone in the blood vessels, producing a decrease in the total peripheral resistance. The resulting decrease in blood pressure stimulates the vagus, thereby producing a reflex tachycardia. Patients who are pretreated with -adrenergic blocking agents and given epinephrine exhibit a predominance of beta effects, which lowers blood pressure. Epinephrine reversal is caused by adrenergic blocking agents.

DIF: Comprehension REF: Sympathetic Autonomic Nervous System (Adrenergic Blocking Agents [Alpha-Adrenergic Blocking Agents]) | p. 42 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 44. The following statements are true of d-tubocurarine except which one? a. It is a competitive nondepolarizing blocker. b. It binds to nicotinic receptors. c. It precipitates malignant hyperthermia in susceptible patients when combined with

halothane. d. It has been used in the Amazon for hunting animals. e. Its action can be overcome by administering neostigmine.

ANS: C

The depolarizing neuromuscular blocker succinylcholine can cause malignant hyperthermia.

Tubocurarine does not. The other statements accurately describe d-tubocurarine.

DIF: Application REF: Sympathetic Autonomic Nervous System (Neuromuscular Blocking Drugs [Nondepolarizing (Competitive) Blockers]) | p. 43 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 45. An

nerve fiber is a sensory fiber, and an autonomic nervous system. a. afferent; efferent b. efferent; afferent c. afferent; neuromuscular junction d. efferent; neuromuscular junction

nerve fiber is a motor fiber in the

ANS: A

The afferent fiber is the sensory fiber. It conducts information toward central integrating areas.

Efferent fibers are motor fibers. They send impulses outward from the CNS to the periphery and produce an action. The reverse is true. The afferent fiber is the sensory fiber and the efferent fiber is the motor fiber. The neuromuscular junction is not found in the autonomic nervous system. It is found in skeletal muscle.

DIF: Comprehension REF: Autonomic Nervous System (Anatomy) | p. 31 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 46. Norepinephrine is the neurotransmitter of the a. pre-ganglionic nerve of the sympathetic division of the autonomic nervous system. b. post-ganglionic nerve of the sympathetic division of the autonomic nervous

system.

c. pre-ganglionic nerve of the parasympathetic division of the autonomic nervous

system. d. post-ganglionic nerve of the parasympathetic division of the autonomic nervous

system.

ANS: B

When the SANS is stimulated, the adrenal medulla releases primarily epinephrine and a small amount of norepinephrine (NE) into the systemic circulation. The fight-or-flight response refers to activation of the sympathetic nervous system. The sympathetic division is designed to cope with sudden emergencies. For example, eyes dilate to acquire more information, and the heart rate increases. Both the pre-ganglionic and post-ganglionic nerves of the parasympathetic division of the autonomic nervous system are stimulated by acetylcholine. The pre-ganglionic nerve of the sympathetic division of the autonomic nervous system is stimulated by acetylcholine as well.

DIF: Recall REF: Autonomic Nervous System (Sympathetic Autonomic Nervous System) | p. 32 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 47. The post-synaptic tissue of the para-sympathetic division of the autonomic nervous system can be

differentiated from the pre-synaptic tissue by response to which chemical? a. Atropine b. Hexamethonium c. Muscarine d. Nicotine ANS: C

This feature allows for the cholinergic synapses to be differentiated from one another. Atropine is a blocking agent for muscarinic sites. Hexamethonium is a blocking agent for nicotinic sites.

Acetylcholine is the neurotransmitter in the synapse formed between preganglionic and postganglionic nerves in both the sympathetic and parasympathetic divisions of the autonomic nervous system.

Because this synapse is also stimulated by nicotine, it is termed nicotinic.

DIF: Recall OBJ: 2

REF: Autonomic Nervous System (Neurotransmitters) | p. 33 TOP: NBDHE, 6.0. Pharmacology

48. Which type of autonomic drug is useful to prepare a patient for an ophthalmologic examination? a. Cholinergic agent b. Anticholinergic agent c. Adrenergic agent d. Adrenergic blocking agent ANS: B

Mydriasis dilates the pupil so that the retina can be examined, and cycloplegia allows for proper measurements to make glasses. Sympathetic stimulation dilates the pupils of the eyes and parasympathetic stimulation constricts them, either a cholinergic agent or an adrenergic blocking agent would not be a correct choice. Adrenergic agents cause a decrease in intraocular pressure, which makes them useful in the treatment of glaucoma and mydriasis.

DIF: Application REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents

[Pharmacologic Effects]) | p. 37

OBJ: 3

TOP: NBDHE, 6.0. Pharmacology

49. Which is true of glycopyrrolate (Robinul)? a. It is a tertiary anticholinergic agent. b. It is a quaternary anticholinergic agent. c. It is lipid soluble and easily penetrates the brain. d. It is a cholinergic agent.

ANS: B

Glycopyrrolate is a quaternary anticholinergic agent used to produce a dry field before some dental procedures. Atropine and scopolamine are tertiary anticholinergic agents. The tertiary agents are lipid soluble, and can easily penetrate the brain.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Pharmacologic Effects]) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 50. Which type of agents will block the muscarinic receptors, but not the nicotinic receptors? a. Cholinergic agents b. Anticholinergic agents c. Adrenergic agents d. Adrenergic blocking agents ANS: B

Anticholinergic drugs block the action of acetylcholine on smooth muscles and the heart. These agents are called antimuscarinic agents because they block the muscarinic receptors and not the nicotinic receptors.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 51. Which type of agent such as donepezil (Aricept) has been FDA approved for the treatment of

dementia? a. Cholinergic agents b. Anticholinergic agents c. Adrenergic agents d. Adrenergic blocking agents ANS: A

Indirect acting, reversible acetylcholinesterase inhibitors are being used to treat Alzheimer Disease (AD) dementia. They have been shown to produce modest improvements in dementia symptoms but they do not slow down, stop, or reverse disease progression. At one time anticholinergic agents were commonly used to reduce tremors associated with Parkinson disease, but at present they are only used occasionally. Some adrenergic agonists have been used to treat attention-deficit disorder (ADD) and narcolepsy.

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Uses]) | p.

37 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

52. Which type of autonomic drugs are first-line therapy for overactive bladder (OAB)? a. Adrenergic agents b. Adrenergic blocking agents c. Cholinergic agents d. Anticholinergic agents ANS: D

These drugs are thought to work by inhibiting acetylcholine/muscarinic receptors in the detrusor muscle of the bladder. Cholinergic action includes urination. For this reason, the best choices would be anticholinergic or adrenergic agents. Anticholinergic drugs currently are first-line therapy for an overactive bladder (OAB).

DIF: Comprehension REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Uses]) | p.

38 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 53. Stimulation of which adrenergic receptor allows the bladder to fill? a. Alpha b. Beta-1 c. Beta-2 d. Beta-3 ANS: D

Beta-3 stimulation relaxes the bladder and allows it to completely fill with urine before sending the message that urination is necessary. Stimulation of alpha receptors causes peripheral vasoconstriction.

Stimulation of beta-1 receptors causes a stimulation of the heart muscle. Stimulation of beta-2 receptors results in bronchodilation.

DIF: Comprehension REF: Sympathetic Autonomic Nervous System (Adrenergic (Sympathomimetic) Agents [Pharmacologic Effects]) | p. 40 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 54. Which category of autonomic drug is used to treat attention-deficit disorder (ADD)? a. Adrenergic agent b. Adrenergic blocking agent c. Cholinergic agent d. Anticholinergic agent ANS: A

Methylphenidate (Ritalin) and dextroamphetamine (Dexedrine) are used to treat ADD in both children and adults. Anticholinergic agent would be the best remaining choice; however, neither adrenergic blocking agents, cholinergic agents, nor anticholinergic agents are used to treat ADD. DIF: Comprehension REF: Sympathetic Autonomic Nervous System (Adrenergic (Sympathomimetic) Agents [Uses]) | p. 41 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE

1. Muscarinic receptors are found in which of the following? (Select all that apply.) a. Central nervous system b. Sympathetic nervous system c. Parasympathetic nervous system d. Neuromuscular junction e. Adrenal medulla ANS: A, B, C

Muscarinic receptors are found only in the central nervous system, sympathetic nervous system, and parasympathetic nervous system. Small doses of acetylcholine (Ach) bind to muscarinic receptors and duplicate the effects of the chemical substance muscarine. Nicotinic receptors are found in the neuromuscular junction and adrenal medulla as well as in the central nervous system and sympathetic and parasympathetic divisions of the autonomic nervous system. Large doses of Ach bind to nicotinic receptors and duplicate the effects of nicotine.

DIF: Application OBJ: 2

REF: Parasympathetic Autonomic Nervous System | p. 35 TOP: NBDHE, 6.0. Pharmacology

TRUE/FALSE 1. Pathways innervating smooth muscles and glands are considered afferent pathways.

ANS: F

Pathways innervating smooth muscles and glands are efferent pathways. They send impulses outward from the CNS to the periphery and produce an action.

DIF: Recall OBJ: 1

REF: Autonomic Nervous System (Anatomy) | p. 31 TOP: NBDHE, 6.0. Pharmacology

2. The fight-or-flight response refers to activation of the parasympathetic nervous system in response to

stress.

ANS: F

The fight-or-flight response refers to activation of the sympathetic nervous system.

DIF: Recall OBJ: 1

REF: Autonomic Nervous System (Functional Organization) | p. 32 TOP: NBDHE, 6.0. Pharmacology

3. Salivation, lacrimation, urination, and defecation refer to toxic effects seen with adrenergic agents.

ANS: F

SLUD (salivation, lacrimation, urination, and defecation) refers to the actions of cholinergic (parasympathomimetic) agents and cholinesterase inhibitors.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Cholinergic (Parasympathomimetic) Agents [Adverse Reactions]) | p. 36 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. Tertiary (ammonium) agents cross the blood-brain barrier better than quaternary (ammonium) agents.

ANS: T

Quaternary ammonium compounds have a permanent positive charge and cannot cross the blood-brain barrier.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Pharmacologic Effects]) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 5. Glycopyrrolate is an -adrenergic agonist used to produce a dry field before some dental procedures.

ANS: F

Glycopyrrolate is an anticholinergic agent used to produce a dry field before some dental procedures.

DIF: Recall REF: Parasympathetic Autonomic Nervous System (Anticholinergic (Parasympatholytic) Agents [Pharmacologic Effects]) | p. 37 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

Chapter 05: Nonopioid (Nonnarcotic) Analgesics Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Pain a. brings people to the dental office. b. keeps people from the dental office. c. can be effectively treated with inactive pills (placebos). d. does all of the above.

ANS: D

All of the above choices are correct. Pain is often the issue that brings the patient to the dental office.

Conversely, pain can be the factor that keeps the patient from seeking dental care at the appropriate time. Because many patients respond when given a placebo, the inclusion of a placebo is required for any acceptable analgesic clinical trials.

DIF: Application REF: Introduction | p. 45 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. The pain threshold varies greatly in individuals because of different perceptions of pain. a. Both parts of the statements are true. b. Both parts of the statements are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: C

The pain threshold does vary greatly in individuals. However, this variation is because of widely different reactions to pain. The two components of pain are perception and reaction. Perception is the physical component of pain and involves the message of pain that is carried through the nerves eventually to the cortex. Reaction is the psychological component of pain and involves the patient’s emotional response to pain. Although individuals are surprisingly uniform in their perception of pain, they vary greatly in their reaction to it.

DIF: Comprehension TOP: NBDHE, 6.0. Pharmacology

REF: Pain | p. 45

OBJ: 1

3. Which of the following raises the pain threshold? a. Emotional instability b. Sympathy c. Sleep d. Both A and C e. Both B and C ANS: E

The pain threshold is raised by sleep, sympathy, activities, and analgesics. A decrease in the pain threshold (a greater reaction to pain) has been said to be associated with emotional instability, anxiety, fatigue, youth, certain nationalities, women, and fear and apprehension. Analgesic therapy must be selected for the individual. A level of discomfort that may not require drug treatment in one person may demand extreme therapy in another.

DIF: Comprehension TOP: NBDHE, 6.0. Pharmacology

REF: Pain | p. 45

OBJ: 1

4. The mechanism of action of nonopioid analgesics is due to a. depression of the central nervous system (CNS). b. decrease in the pain threshold. c. inhibition of prostaglandin synthesis. d. stimulation of synthesis of prostaglandins.

ANS: C

Prostaglandins sensitize pain receptors to substances such as bradykinin. The action of the nonopioid analgesics is related to their ability to inhibit prostaglandin synthesis. Opioid analgesics are called narcotic, central, or strong analgesics. Opioid analgesics depress the central nervous system, nonopioid analgesics act primarily at the peripheral nerve endings. Prostaglandins can lower the pain threshold to painful stimuli, cause inflammation and fever, and affect vascular tone and permeability. Analgesics work by raising the pain threshold.

DIF: Comprehension REF: Classification | p. 45 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 5. Nonopioid analgesics act primarily at the peripheral nerve endings, although their antipyretic effect is

mediated centrally. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false.

d. The first statement is false, the second statement is true.

ANS: A

Nonopioid analgesics act primarily at the peripheral nerve endings, although their antipyretic effect is mediated centrally. Opioids act primarily within the central nervous system (CNS).

DIF: Recall REF: Classification | p. 45 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

6. The action of nonopioid analgesics is related to their ability to inhibit a. the CNS. b. prostaglandin synthesis. c. release of epinephrine. d. release of acetylcholine.

ANS: B

Nonopioid analgesics work by inhibiting prostaglandin synthesis. The opioids affect the response to pain by depressing the CNS. DIF: Recall REF: Classification | p. 45 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

7. Which of the following choices has antiinflammatory, antipyretic, analgesic, and antiplatelet action? a. Acetaminophen b. Codeine c. Aspirin d. Hydrocodone ANS: C

Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) have antiinflammatory, antipyretic, analgesic, and antiplatelet actions. Acetaminophen has antipyretic and analgesic action. Hydrocodone has analgesic action.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Mechanism of Action]) | p. 46 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. Prostaglandins sensitize pain receptors to a. diflunisal. b. salsalate. c. bradykinin. d. ketoprofen.

ANS: C

Prostaglandins, which are lipids that are synthesized locally by inflammatory stimuli, can sensitize the pain receptors to substances such as bradykinin. Prostaglandins can also lower the pain threshold to painful stimuli, cause inflammation and fever, and affect vascular tone and permeability, which results in edema. Therefore a reduction in prostaglandin results in a reduction in pain. Diflunisal and salsalate are both salicylates, and ketoprofen is an NSAID. DIF: Recall

REF: Salicylates (Acetylsalicylic Acid [Mechanism of Action]) | p. 46

OBJ: 2

TOP: NBDHE, 6.0. Pharmacology

9. Which of the following statements is true concerning the pharmacokinetics of aspirin? a. Plain, unbuffered aspirin produces its peak effect on an empty stomach in 15

minutes. b. Buffered aspirin has a slower peak of aspirin than plain aspirin. c. The half-life of unhydrolyzed aspirin is approximately 90 minutes. d. Aspirin exhibits zero-order kinetics.

ANS: D

Aspirin exhibits zero-order kinetics, meaning that a constant amount rather than a constant percentage of the drug is metabolized per hour. Plain, unbuffered aspirin produces its peak effect on an empty stomach in 30 minutes. The buffered tablet reaches its peak in approximately 20 minutes. Buffered aspirin preparations have a somewhat quicker peak of action and attain higher blood levels because buffering facilitates dispersion and dissolution. The half-life of unhydrolyzed aspirin is approximately 15 minutes.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Pharmacokinetics]) | p. 47 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 10. The ability of aspirin to reduce fever results from its inhibition of prostaglandin synthesis in the a. medulla. b. hypothalamus. c. pons. d. cerebellum.

ANS: B

Hypothalamic prostaglandin synthesis is caused by elevated blood levels of leukocyte pyrogens induced by inflammation. Increased hypothalamic prostaglandin levels produce increased body temperature. The inhibition of hypothalamic prostaglandin synthesis results in a return to a more normal body temperature. Aspirin inhibits prostaglandin synthesis in the hypothalamus.

DIF: Recall OBJ: 2

REF: Salicylates (Acetylsalicylic Acid [Pharmacologic Effects]) | p. 47 TOP: NBDHE, 6.0. Pharmacology

aggregation of platelets and thromboxane A2 11. Prostacyclin a. stimulates; stimulates b. stimulates; inhibits c. inhibits; stimulates d. inhibits; inhibits

aggregation of platelets.

ANS: C

Depending on the dose, aspirin can inhibit either prostacyclin or thromboxane A2. Further studies are needed to determine aspirin’s usefulness and dose in preventing clotting events in different patient populations. Prostacyclin inhibits aggregation of platelets and thromboxane A2 stimulates aggregation of platelets.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Pharmacologic Effects]) | p. 47

OBJ: 2

TOP: NBDHE, 6.0. Pharmacology

12. Which of the following is the most common side effect from aspirin? a. Gastrointestinal effects b. Bleeding c. Hepatic and renal effects d. Hypersensitivity ANS: A

Gastrointestinal effects may be simple dyspepsia, nausea, vomiting, or gastric bleeding. These adverse effects result from direct gastric irritation and inhibition of prostaglandins. Because prostaglandins are responsible for inhibition of gastric acid secretion and stimulation of the cytoprotective mucus in the stomach, aspirin counteracts these effects. Aspirin’s most frequent side effect is related to the gastrointestinal tract.

DIF: Recall OBJ: 2

REF: Salicylates (Acetylsalicylic Acid [Adverse Reactions]) | pp. 47-48 TOP: NBDHE, 6.0. Pharmacology

13. Which of the following statements is true regarding aspirin and the clotting mechanism? a. Aspirin reversibly interferes with the clotting mechanism by reducing platelet

adhesiveness. b. Replacement of all of the affected platelets is required to produce normal clotting. c. With lower doses of aspirin, 1 1/2 days should elapse to obtain normal clotting. d. Aspirin stimulates production of prothrombin.

ANS: C

1 1/2 days should elapse to obtain normal clotting with lower doses of aspirin. With large doses of aspirin, the half-life is prolonged. Aspirin irreversibly interferes with the clotting mechanism by reducing platelet adhesiveness. Replacement of all of the affected platelets is not required to produce normal clotting. After approximately 20% of the platelets have been replaced with newly formed platelets, clotting will return to normal by approximately 36 hours. Aspirin inhibits the production of prothrombin, resulting in hypoprothrombinemia.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Adverse Reactions]) | p. 48 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 14. Aspirin can be used most safely in patients who a. have arthritis. b. have gout. c. have ulcers. d. are pregnant.

ANS: A

Aspirin is commonly used in patients to relieve the pain and inflammation of rheumatoid arthritis.

Small doses of aspirin can produce uric acid retention and exacerbate gout. Aspirin may exacerbate preexisting ulcers. Aspirin abuse, or high dose use at near term, can be detrimental to the fetus or the newborn.

DIF: Application

REF: Salicylates (Acetylsalicylic Acid [Uses]) | p. 49

OBJ: 2

TOP: NBDHE, 6.0. Pharmacology

15. Which of the following is the best to use in pediatric patients for both its analgesic and antipyretic

action? a. Aspirin b. Acetaminophen c. NSAIDs d. Codeine ANS: B

Acetaminophen is used in place of aspirin for pediatric patients for both its analgesic and antiinflammatory action. In children and adolescents with either chickenpox or influenza, the use of aspirin has been epidemiologically associated with Reye syndrome.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Adverse Reactions]) | p. 48 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 16. The incidence of true aspirin allergy is a. approximately 10%. b. between 2% and 5%. c. less than 1%. d. unknown; it has not ever been recorded.

ANS: C

Many patients with “allergy to aspirin” in their charts, on questioning, actually have stomach problems rather than a true allergy. In the patient’s chart, differentiating aspirin’s adverse reactions from its hypersensitivity reactions is important. Patients with true aspirin hypersensitivity cannot be given any of the NSAIDs because of some cross-hypersensitivity. Allergic reactions can vary from rash, wheezing, urticaria, and angioneurotic edema to anaphylactic shock. The incidence of true aspirin allergy is less than 1% (0.2% to 0.4%).

DIF: Recall OBJ: 2

REF: Salicylates (Acetylsalicylic Acid [Adverse Reactions]) | p. 48 TOP: NBDHE, 6.0. Pharmacology

17. Which of the following drugs can be substituted for aspirin in patients displaying the aspirin

hypersensitivity triad? a. Ibuprofen b. Naproxen c. Codeine d. Piroxicam ANS: C

Codeine is not a NSAID. Patients displaying the aspirin hypersensitivity triad show crosshypersensitivity between aspirin and other agents, including the NSAIDs, and they should not be given any NSAIDs. Ibuprofen, naproxen, and piroxicam are all NSAIDs. DIF: Application OBJ: 2

REF: Salicylates (Acetylsalicylic Acid [Adverse Reactions]) | pp. 48-49 TOP: NBDHE, 6.0. Pharmacology

18. All of the following are characteristics of aspirin toxicity (salicylism) except a. dimness of vision. b. hyperthermia. c. electrolyte imbalance. d. hepatic necrosis. e. tinnitus.

ANS: D

Hepatic necrosis is a characteristic of acetaminophen toxicity and is rarely seen with aspirin use. The toxic metabolite of acetaminophen that contributes to hepatic necrosis is N-acetyl-p-benzoquinone.

The Food and Drug Administration (FDA) has recommended tighter dose controls and warnings with acetaminophen use in the hopes of preventing even more cases of accidental liver toxicity. All the other choices are characteristics of aspirin toxicity.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Toxicity]) | p. 49 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 19. A drug interaction between aspirin and a. probenecid b. warfarin c. methotrexate d. sulfonylureas

can result in significant bleeding.

ANS: B

The drug interaction between aspirin and warfarin can result in bleeding. Warfarin is an oral anticoagulant that is highly protein bound to plasma protein–binding sites. If aspirin is administered to a patient taking warfarin, it can displace the warfarin from its binding sites, increasing its anticoagulant effect. Aspirin interferes with probenecid’s uricosuric effect and has been reported to precipitate an acute attack of gout. Aspirin can displace methotrexate from its plasma protein–binding sites and can also interfere with its clearance. This results in an increased serum concentration and methotrexate toxicity such as bone marrow depression. Higher doses of salicylates may produce a hypoglycemic effect.

DIF: Recall OBJ: 2

REF: Salicylates (Acetylsalicylic Acid [Drug Interactions]) | p. 49 TOP: NBDHE, 6.0. Pharmacology

20. What is the usual adult dosage of aspirin for the treatment of pain or fever? a. 250 mg every 4 hours b. 3 to 6 g per day c. 650 mg every 4 hours d. 800 mg every 4 hours e. 160 mg per day ANS: C

Two 325-mg tablets every 4 hours. Aspirin doses are generally measured on a per tablet basis (325 mg = 5 g). The dose for arthritis is 3 to 6 g per day, and the dose for prevention of myocardial infarction is one half tablet daily.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Doses and Preparations]) | p. 49

OBJ: 2

TOP: NBDHE, 6.0. Pharmacology

21. A person should

aspirin if he or she suspects he or she may be having a heart attack provided there is not an aspirin allergy, hypersensitivity, or another contraindication. a. completely avoid b. chew one low dose c. take the maximum daily recommended dose of 4,000 mg of d. take 325 to 650 mg every 4 hours of ANS: B

Patients should call 9-1-1 first and wait for their instructions before taking the aspirin tablet. The aspirin tablet can be administered once the emergency responder is present, in the ambulance, or in the emergency room. Patients experiencing a myocardial infarction are usually advised by emergency responders to chew one low dose aspirin at the onset of symptoms.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Uses]) | p. 49 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 22. Caffeine is often combined with aspirin because caffeine potentiates the analgesic effect of aspirin and

other analgesics. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: A

The addition of 130 mg of caffeine is equivalent to increasing the dose of the analgesic by one third or more. The caffeine in most proprietary aspirin preparations is at an active level for a single dose. Most proprietary aspirin preparations contain caffeine, and caffeine does significantly potentiate the analgesic effect of aspirin and other analgesics.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Doses and Preparations]) | p. 50 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 23. Which of the following agents would be least useful in alleviating fever? a. Piroxicam b. Acetaminophen c. Diflunisal d. Probenecid e. Aspirin ANS: C

Diflunisal (Dolobid) is a nonacetylated salicylic acid classified as a nonsteroidal antiinflammatory drug (NSAID). It is as effective as the other NSAIDs in the treatment of pain, but is the least useful in alleviating fever. Diflunisal does not have clinically useful antipyretic activity.

DIF: Comprehension REF: Salicylates (Diflunisal) | p. 50 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

24. Which of the following is true concerning NSAIDs? a. Many prescribers agree that the NSAIDs are the most useful drug group for the

treatment of dental pain. b. Unlike aspirin, NSAIDs do not inhibit the enzyme cyclooxygenase (COX). c. Most NSAIDs reach a peak blood level in approximately 20 minutes. d. NSAIDs do not have a significant antiinflammatory effect.

ANS: A

Many authors agree that the NSAIDs are the most useful drug group for the treatment of dental pain.

Similar to aspirin, NSAIDs inhibit the enzyme COX (prostaglandin synthase), resulting in a reduction in the formation of prostaglandin precursors and thromboxanes from arachidonic acid. All of the currently available NSAIDs inhibit both COX I and COX II. COX I is a widely distributed constitutive enzyme responsible for all the adverse reactions of the NSAIDs such as stomach problems, reduced renal function, fluid retention, and reduced platelet adhesiveness. COX II is an inducible enzyme that is synthesized only when inflammation occurs.

DIF: Comprehension REF: Nonsteroidal Antiinflammatory Drugs | p. 50 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 25. Adverse cardiovascular effects are thought to be least likely to occur with the use of which of the

following nonsteroidal antiinflammatory drugs (NSAIDs)? a. Celecoxib (Celebrex) b. Naproxen (Naprosyn) c. Diclofenac (Voltaren) d. Ketoprofen (Orudis) ANS: B

Naproxen (Naprosyn) and naproxen sodium OTC (Aleve) are propionic acid derivatives. They have slightly longer half-lives than ibuprofen and can be dosed on an 8- to 12-hour schedule. Aleve is dosed 220 mg every 8 to 12 hours not to exceed two tablets in the 8 to 12 hour time period. Their pharmacologic effects, adverse reactions, and efficacy are similar to those of ibuprofen. Higher doses of celecoxib (Celebrex) are associated with increased risk of adverse cardiovascular effects. Celecoxib has been associated with cholestatic jaundice, which may be related to sulfonamide allergy. The risk is highest with diclofenac (Voltaren) and lowest with naproxen (Naprosyn).

DIF: Comprehension REF: Nonsteroidal Antiinflammatory Drugs (Adverse Reactions [Cardiovascular Effects]) | p. 51 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 26. Which of the following statements is true concerning adverse reactions of NSAIDs? a. NSAIDs will decrease acid secretion in the stomach. b. Tolerance develops to the use of NSAIDs. c. NSAIDs irreversibly inhibit platelet aggregation because they inhibit thromboxane

A2 production. d. NSAIDs have precipitated renal insufficiency.

ANS: D

All NSAIDs, including celecoxib, inhibit renal prostaglandins, decrease renal blood flow, cause fluid retention, and may cause hypertension and renal failure in some patients, especially the elderly. The NSAIDs have little effect on the patient with normal kidney function; however, with renal disease, decreases in both renal blood flow and glomerular filtration rate can occur. Prostaglandin inhibitors, such as NSAIDs, can interfere with the normal protective mechanisms in the stomach and increase acid secretion, causing symptoms or even an ulceration or perforation. These agents are not addicting, tolerance does not develop, and no withdrawal syndrome can be induced. NSAIDs reversibly inhibit platelet aggregation because they inhibit thromboxane A2 production. In contrast to aspirin, their effect remains only as long as the drug is present in the blood: 1 day for ibuprofen, 4 days for naproxen, and 2 weeks for oxaprozin.

DIF: Comprehension REF: Nonsteroidal Antiinflammatory Drugs (Adverse Reactions [Renal Effects]) | pp. 51-52 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27. Which of the following NSAIDs is the best choice for a patient to take if a blood clotting test is

required soon following administration of the NSAID? a. Naproxen (Naprosyn) b. Ibuprofen (Motrin) c. Oxaprozin (Daypro) d. Meloxicam (Mobic) ANS: B

Ibuprofen has the shortest half-life of these choices. In contrast to aspirin, an NSAID’s effect only lasts as long as the drug is present in the blood. Ibuprofen remains in the blood for 1 day (half-life 1.8 to 2.5 hours), naproxen 4 days (half-life 12 to 15 hours), and oxaprozin 2 weeks (half-life 50 hours).

DIF: Application REF: Nonsteroidal Antiinflammatory Drugs (Adverse Reactions [Pregnancy and Nursing Considerations]) | p.

52 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 28. Which of the following NSAIDs is the drug of choice for treating a nursing woman? a. Naproxen b. Diflunisal c. Ibuprofen d. Fenoprofen ANS: C

Ibuprofen is the drug of choice for treating a nursing woman. Fenoprofen and mefenamic acid are present in small quantities in breast milk. Small amounts of both naproxen and diflunisal are excreted in breast milk.

DIF: Recall REF: Nonsteroidal Antiinflammatory Drugs (Adverse Reactions [Pregnancy and Nursing Considerations]) | p.

52 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 29. Which of the following agents is known to have a drug interaction with lithium? a. Aspirin b. Naproxen c. Acetaminophen

d. Oxycodone ANS: B

NSAIDs such as naproxen are known to increase serum levels of lithium. Aspirin, acetaminophen, and oxycodone do not have this interaction with lithium.

DIF: Comprehension REF: Nonsteroidal Antiinflammatory Drugs (Specific Nonsteroidal Antiinflammatory Drugs [Naproxen Sodium]) | p. 54 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 30. Dental pain following a simple tooth extraction is best managed with which of the following choices? a. Codeine 60 mg b. Ibuprofen 400 mg c. Acetaminophen 650 mg d. Aspirin 650 mg e. Placebo ANS: B

In usual prescription doses, NSAIDs can be shown to be statistically significantly better than codeine alone, aspirin, acetaminophen, or placebo. Usual analgesic doses of NSAIDs have been shown to be as effective as 650 mg of aspirin or acetaminophen plus 60 mg of codeine and even as effective as the intermediate-strength opioid combinations.

DIF: Application REF: Nonsteroidal Antiinflammatory Drugs (Therapeutic Uses [Dental]) | p. 52 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 31. Which of the following NSAIDs is considered the drug of choice for management of dental pain when

a NSAID is indicated? a. Naproxen b. Naproxen sodium c. Ibuprofen d. Diflunisal ANS: C

Ibuprofen is considered the drug of choice for management of dental pain when a NSAID is indicated.

Naproxen and naproxen sodium are propionic acid NSAIDs that have slightly longer half-lives than ibuprofen and can be administered on an 8- to 12-hour schedule. Other NSAIDs, such as fenoprofen, ketorolac, or diflunisal, may be used for patients who do not respond to either ibuprofen or naproxen sodium.

DIF: Recall REF: Nonsteroidal Antiinflammatory Drugs (Specific Nonsteroidal Antiinflammatory Drugs [Ibuprofen]) | p.

53 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 32. Oral administration with

(IM) therapy. a. fenoprofen b. ketorolac c. naproxen sodium

is indicated only as continuation to intravenous (IV) or intramuscular

d. diflunisal ANS: B

Ketorolac is an NSAID indicated for the short-term management of moderately severe acute pain that requires analgesia at the opioid level. It is contraindicated as a prophylactic analgesic before any major surgery when hemostasis is critical because of the increased risk of bleeding. Oral administration with ketorolac is indicated only as continuation to IV or IM therapy. Ketorolac is a newer NSAID; it is equivalent in efficacy to the other NSAIDs; however, unlike other NSAIDs, it is available parenterally.

DIF: Recall REF: Nonsteroidal Antiinflammatory Drugs (Specific Nonsteroidal Antiinflammatory Drugs [Other Nonsteroidal Antiinflammatory Drugs]) | p. 54 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 33. Which of the following statements is true of COX II? a. It is a widely distributed constitutive enzyme. b. It is responsible for the adverse reactions of the NSAIDs. c. It is synthesized only when inflammation occurs. d. It is not an enzyme.

ANS: C

COX II is an inducible enzyme that is only synthesized when inflammation occurs. COX I is a widely distributed constitutive enzyme responsible for the adverse reactions of the NSAIDs such as stomach problems, reduced renal function, fluid retention, and reduced platelet adhesiveness.

DIF: Recall OBJ: 3

REF: Nonsteroidal Antiinflammatory Drugs (Mechanism of Action) | p. 50 TOP: NBDHE, 6.0. Pharmacology

34. Which of the following choices is currently the most popular COX II–specific agent on the market? a. Celecoxib b. Rofecoxib c. Valdecoxib d. Indomethacin ANS: A

Celecoxib is currently the most popular COX II–specific agent; it is indicated for arthritis. Rofecoxib and valdecoxib were removed from the U.S. market in 2005 as a result of a high incidence of cardiovascular events associated with these two drugs. Indomethacin is a COX I–specific medication.

DIF: Comprehension REF: Nonsteroidal Antiinflammatory Drugs (Cyclooxygenase II-Specific Agents) | p. 54 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 35. Which of the following statements is true regarding the pharmacokinetics of acetaminophen? a. Acetaminophen is slowly and incompletely absorbed from the gastrointestinal

tract. b. Acetaminophen is excreted with a half-life of 8 to 12 hours. c. When large doses of acetaminophen are ingested, an intermediate metabolite is

produced that is thought to be hepatotoxic. d. Acetaminophen is less potent and efficacious than aspirin.

ANS: C

An intermediate metabolite is produced when large doses of acetaminophen are ingested that is thought to be hepatotoxic and possibly nephrotoxic. Acetaminophen is rapidly and completely absorbed from the gastrointestinal tract, achieving a peak plasma level in 1 to 3 hours. After therapeutic doses, it is excreted with a half-life of 1 to 4 hours. Acetaminophen and aspirin are equally efficacious and equally potent.

DIF: Comprehension REF: Acetaminophen (Pharmacokinetics) | p. 54 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 36. Acetaminophen does not possess any of these clinically significant

effects: (1) antipyretic, (2)

antiinflammatory, (3) analgesic. a. 1, 2, 3 b. 1 and 2 c. 1 and 3 d. 1 e. 2 ANS: E

Acetaminophen is thought to produce analgesia by elevating the pain threshold. Its potential mechanism of action may involve inhibiting the nitric oxide pathway, which is mediated by a variety of neurotransmitter receptors. Its antipyretic effects may be the result of inhibition of endogenous pyrogens on the heat-regulating centers of the brain by blocking the formation and release of prostaglandins in the central nervous system. Acetaminophen does have clinically significant antipyretic and analgesic effects; however, it does not possess any clinically significant antiinflammatory effect.

DIF: Comprehension REF: Acetaminophen (Pharmacologic Effects) | p. 54 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 37. Which of the following is true regarding these pharmacologic effects of therapeutic doses of

acetaminophen? (1) No effect on the cardiovascular system. (2) Does not produce gastric bleeding. (3) Does not affect platelet adhesiveness. (4) Does not affect uric acid excretion. a. 1, 2, 3, 4 b. 1, 2, 3 c. 2, 3, 4 d. 1 only ANS: A

All of the above are true regarding the pharmacologic effects of therapeutic doses of acetaminophen.

Therapeutic doses of acetaminophen have no effect on the cardiovascular or respiratory system. In contrast to aspirin, acetaminophen does not produce gastric bleeding or affect platelet adhesiveness or uric acid excretion.

DIF: Comprehension REF: Acetaminophen (Pharmacologic Effects) | p. 54 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 38. An acute overdose with acetaminophen may damage the a. eyes.

b. liver. c. spleen. d. kidney.

ANS: B

Acute overdose of acetaminophen can lead to the generation of a toxic metabolite that can cause hepatic necrosis and lead to death. The acute ingestion of more than 12 g of acetaminophen in single ingestion is considered a toxic dose and can pose a high risk for liver damage. Acetaminophen does not damage the eyes or the spleen but can damage the kidney upon chronic administration.

DIF: Recall OBJ: 4

REF: Acetaminophen (Adverse Reactions [Hepatic Effects]) | pp. 54-55 TOP: NBDHE, 6.0. Pharmacology

39. Who is most likely to experience the most cases of accidental overdose with acetaminophen? a. Infants b. Children c. Young adults d. Older adults ANS: B

In children, the acute ingestion of 250 mg/kg poses a high risk for liver damage and the acute ingestion of 350 mg/kg can cause severe hepatotoxicity if not immediately treated. Children experience more cases of accidental overdose with acetaminophen, which occurs because the wrong dose form is used (e.g., infant drops are given to older children or adult doses are given to children). Infant drops are concentrated, and doses for toddlers to 11-year-old children are not the same as doses for infants.

Parents may give the infant liquid to the older child and pour it in the measuring cup, not realizing that they have overdosed their child.

DIF: Comprehension REF: Acetaminophen (Adverse Reactions [Hepatic Effects]) | pp. 54-55 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 40. Alcohol consumption stimulates the breakdown of acetaminophen, thereby decreasing the toxic

potential of acetaminophen use. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: C

Depending on the amount of alcoholic beverages consumed, the maximum dose of acetaminophen varies. The normal maximum dose of acetaminophen (4 g) may be used in patients who usually do not drink alcohol. The dose should be restricted to 2 g if a patient is a moderate drinker (less than three alcohol beverages daily). Alcohol stimulates the oxidizing enzymes that metabolize acetaminophen to its toxic metabolite. In this way, it increases acetaminophen toxicity.

DIF: Application OBJ: 4

REF: Acetaminophen (Adverse Reactions [Hepatic Effects]) | p. 55 TOP: NBDHE, 6.0. Pharmacology

41. Which drug carries a safety warning regarding the risk of three rare, but potentially fatal, skin reactions

associated with? a. Aspirin and salicylates b. NSAIDs c. Acetaminophen d. Colchicine ANS: C

This warning advised that anyone with a skin reaction, such as rash or blister, while taking acetaminophen stop taking it and seek immediate medical care. It was made based upon a review of the medical literature and reports of adverse reactions to the FDA. Acetaminophen now carries a safety warning because of the risk of Stevens-Johnson syndrome, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis.

DIF: Recall OBJ: 4

REF: Acetaminophen (Adverse Reactions [Skin Reactions]) | p. 55 TOP: NBDHE, 6.0. Pharmacology

42. Which of the following agents is intended to treat an acute attack of gout? a. Probenecid b. Codeine c. Colchicine d. Acetaminophen e. Both A and C ANS: C

Colchicine is used for acute attacks of gout. Probenecid is used in prevention of a gout attack. Codeine and acetaminophen are not recommended for treating gout.

DIF: Recall OBJ: 5

REF: Drugs Used to Treat Gout (Colchicine) | p. 56 TOP: NBDHE, 6.0. Pharmacology

43. Which of the following agents is a xanthine oxidase inhibitor? a. Colchicine b. Ibuprofen c. Allopurinol d. Probenecid ANS: C

Allopurinol is the only drug listed that inhibits xanthine oxidase. Colchicine appears to inhibit the chemotactic property of leukocytosis and interfere with the inflammatory response to urate crystals.

Ibuprofen is a nonsteroidal antiinflammatory. Probenecid blocks the tubular reabsorption of filtered urate, prevents formation of new urate crystals called tophi, and mobilizes those present.

DIF: Recall OBJ: 5

REF: Drugs Used to Treat Gout (Allopurinol) | p. 56 TOP: NBDHE, 6.0. Pharmacology

44. Each of the following is an indication for the use of NSAIDs except one. Which is the exception? a. Dysmenorrhea b. Gouty arthritis c. Known aspirin hypersensitivity

d. Asthma ANS: C

NSAIDs should not be used in patients with known aspirin hypersensitivity reactions. Medical uses of NSAIDs involve many conditions, including osteoarthritis, rheumatoid arthritis, gouty arthritis, fever, dysmenorrhea, and pain. NSAIDs should be used with caution in persons with preexisting asthma because patients with asthma may have aspirin hypersensitivity which can cause severe bronchospasm that can be fatal. Since cross-sensitivity between aspirin and NSAIDs has been reported, NSAIDs should not be used in patients with known aspirin hypersensitivity.

DIF: Comprehension REF: Nonsteroidal Antiinflammatory Drugs (Contraindications and Cautions) | p. 52 | Nonsteroidal Antiinflammatory Drugs (Therapeutic Uses [Medical]) | p. 52 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 45. Febuxostat (Uloric) is used to treat a. fever in a young child. b. dental pain when an NSAID is indicated. c. certain kinds of cancer and autoimmune diseases. d. gout.

ANS: D

Febuxostat (Uloric) is a xanthine oxidase inhibitor used to treat chronic gout and hyperuricemia.

Acetaminophen is the best choice to treat fever in a young child. Ibuprofen is the drug of choice for treatment of dental pain when an NSAID is indicated. Methotrexate (MTX) is an antineoplastic drug used to treat certain kinds of cancer.

DIF: Recall OBJ: 5

REF: Drugs Used to Treat Gout (Febuxostat) | p. 56 TOP: NBDHE, 6.0. Pharmacology

46. Rheumatoid arthritis (RA) is most likely to involve which part of the body? a. Liver b. Brain c. Bones d. Kidneys ANS: C

Rheumatoid arthritis affects the joint linings causing painful inflammation and swelling. This can lead to bone erosion and joint deformity. Rheumatoid arthritis is characterized by chronic inflammation of the body’s joints including the hands and feet.

DIF: Comprehension REF: Drugs Used to Treat Arthritis | p. 56 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 47. Aspirin should not be given to a child until he or she is 18 years of age because a. the tablets are too difficult to swallow. b. there is a risk of Reye syndrome. c. aspirin is a narcotic and requires a prescription. d. aspirin has been associated with hepatotoxicity.

ANS: B

Administration of aspirin to children with either chickenpox or influenza has been associated with Reye syndrome, which can be fatal. The reason is due to Reye syndrome, not tablet size. Aspirin is not a narcotic, it is a nonnarcotic analgesic and does not require a prescription. Hepatotoxicity is associated with acetaminophen rather than aspirin. It is rare to see hepatotoxicity associated with the use of aspirin.

DIF: Recall REF: Salicylates (Acetylsalicylic Acid [Box 5.3: Patient Instructions for Use of Aspirin]) | p. 49 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 48. Salicylism is a toxic effect from a. aspirin (ASA). b. acetaminophen (Tylenol). c. ibuprofen (Advil). d. azathioprine (Imuran).

ANS: A

Salicylism is characterized by tinnitus, headache, nausea, vomiting, dizziness, and dimness of vision.

With higher blood levels, stimulation of respiration leads to hyperventilation, which produces respiratory alkalosis. Acetaminophen is not a salicylate and does not cause salicylism. Ibuprofen is an NSAID and does not produce salicylism. Azathioprine is a disease modifying-antirheumatic drug and does not produce salicylism.

DIF: Comprehension REF: Salicylates (Acetylsalicylic Acid [Toxicity]) | p. 49 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 49. Which drug is a biologic response modifier used to treat rheumatic arthritis? a. Rituximab (Rituxan) b. Sulfasalazine (Azulfidine) c. Adalimumab (Humira) d. Etanercept (Enbrel) ANS: A

Rituximab is a monoclonal antibody that reduces circulating B cells. It reduces inflammation by reducing mediators of the inflammatory response. Sulfasalazine is an immunosuppressive that targets the immune system. Adalimumab is a tumor necrosis factor-alpha inhibitor that is referred to as a monoclonal antibody. Etanercept is a fusion protein that inhibits tumor necrosis factor-alpha.

DIF: Recall OBJ: 2

REF: Drugs Used to Treat Arthritis (Biologic Response Modifiers) | p. 57 TOP: NBDHE, 6.0. Pharmacology

MULTIPLE RESPONSE 1. Low-dose aspirin therapy is recommended for which of the following? (Select all that apply.) a. People who have had heart bypass surgery b. Men aged 45 to 79 with no history of heart disease c. Women aged 55 to 79 with no history of heart disease d. A person with gastroesophageal reflux disease (GERD) ANS: A, B, C

Clinical trials have shown that daily use of aspirin as a secondary preventive measure can reduce allcause mortality by 18% and myocardial infarctions by 30% in persons with known cardiovascular disease. Aspirin can also be used as preventive therapy in persons who have not experienced a heart attack or stroke but are at increased risk for these events. Salicylates may exacerbate preexisting conditions such as ulcers, gastritis, hiatal hernia, or GERD. Aspirin can be of benefit to persons that have already had a stroke, heart attack, angina, peripheral vascular disease, or in persons that have had angioplasty or bypass surgery. The U.S. Preventative Service Task Force recommends that men with no history of heart disease or stroke, aged 45 to 79 years of age take low-dose aspirin each day to prevent a myocardial infarction and women with no history of heart attack or stroke, aged 55 to 79 take low-dose aspirin each day to prevent a stroke. The benefit of aspirin therapy must outweigh the risk of many adverse effects associated with aspirin therapy, especially gastrointestinal bleeding.

DIF: Application OBJ: 2

REF: Salicylates (Acetylsalicylic Acid [Uses]) | p. 49 TOP: NBDHE, 6.0. Pharmacology

2. NSAIDs carry “black box warnings” for which of the following types of events? (Select all that

apply.) a. Respiratory b. Gastrointestinal c. Cardiovascular d. Endocrine ANS: B, C

Gastrointestinal and cardiovascular. The Food and Drug Administration (FDA) requires that a black box be placed around serious adverse and even fatal effects with certain drugs. It is the strongest warning possible. All NSAIDs may cause an increased risk of serious cardiovascular (CV) thrombotic events, myocardial infarction, and stroke, which all may be fatal. All NSAIDs increase the risk for serious gastrointestinal events including bleeding, ulceration, and perforation of the stomach or intestine, which may be fatal.

DIF: Comprehension REF: Nonsteroidal Antiinflammatory Drugs (Contraindications and Cautions) | p. 52 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Two components of pain include perception and reaction.

ANS: T

Perception and reaction are two distinct components of pain.

DIF: Recall

REF: Pain | p. 45

OBJ: 1

TOP: NBDHE, 6.0. Pharmacology

2. Raising the pain threshold increases one’s reaction to pain.

ANS: F

Lowering the pain threshold increases one reaction to pain.

DIF: Recall

REF: Pain | p. 45

OBJ: 1

TOP: NBDHE, 6.0. Pharmacology

3. Salicylates’ mechanism of action involves inhibiting prostaglandin synthesis.

ANS: T

Salicylates inhibit the COX enzyme, which produces prostaglandins.

DIF: Recall OBJ: 2

REF: Salicylates (Acetylsalicylic Acid [Mechanism of Action]) | p. 46 TOP: NBDHE, 6.0. Pharmacology

4. Aspirin should not be given to children until they are 18 years of age.

ANS: T

Administration of aspirin to children with either chickenpox or influenza has been associated with Reye syndrome, which can be fatal.

DIF: Recall OBJ: 2

REF: Box 5.3: Patient Instructions for Use of Aspirin | p. 49 TOP: NBDHE, 6.0. Pharmacology

5. Salicylism is a toxic effect from acetaminophen.

ANS: F

Acetaminophen is not a salicylate and does not cause salicylism.

DIF: Recall REF: Salicylates (Acetylsalicylic Acid [Toxicity]) | p. 49 | Acetaminophen | p. 54 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 6. Probenecid and allopurinol both inhibit the synthesis of uric acid.

ANS: F

Allopurinol inhibits the synthesis of uric acid, but probenecid increases the excretion of uric acid.

DIF: Recall REF: Drugs Used to Treat Gout (Allopurinol) | p. 56 | Drugs Used to Treat Gout (Probenecid) | p. 56 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology

Chapter 06: Opioid (Narcotic) Analgesics and Antagonists Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Enkephalins, endorphins, and dynorphins probably function as

has not been elucidated. a. prostaglandins b. neurotransmitters c. sedative-hypnotics d. enzymes ANS: B

, although their exact function

Enkephalins, endorphins, and dynorphins are endogenous substances with opioid-like action. They probably function as neurotransmitters. They may be involved in the analgesic action of a placebo and the enhancement of well-being that occurs with running. Prostaglandins are produced in the body in response to many different stimuli. Prostaglandins are thought to be mediators of the inflammatory response in oral soft tissues and may be involved in the initial stage of periodontal disease. Sedativehypnotics produce varying degrees of central nervous system (CNS) depression depending on the dose administered. Examples include benzodiazepines, barbiturates, and nonbenzodiazepine-nonbarbiturate sedative-hypnotics. An enzyme is a substance that catalyzes a chemical reaction without being changed by it.

DIF: Recall REF: Mechanism of Action | p. 58 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. Beta-endorphin is a naturally occurring peptide with opioid-like action. It possesses analgesic action

but has no addiction potential. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second statement is false. d. The first statement is false; the second statement is true.

ANS: C

Endorphins, enkephalins, and dynorphins are naturally occurring peptides with opioid-like action.

Endorphins, enkephalins, and dynorphins possess analgesic action and have addiction potential. An increase in beta-endorphins is associated with “runners high,” the enhancement of well-being associated with running.

DIF: Application REF: Mechanism of Action | p. 58 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. Morphine has its most potent action on the

most potent action on the a. mu; kappa b. mu; delta c. sigma; delta d. kappa; mu e. delta; kappa

class of opioid receptors, and pentazocine has its class of opioid receptors.

ANS: A

The three opioid receptors that have been characterized in more detail and that are stimulated by the opioids are the mu, kappa, and delta receptors. Other opioid receptors include sigma and epsilon.

Stimulation of sigma receptors is associated with autonomic stimulation, dysphoria, hallucinations, nightmares, and anxiety. It is thought that stimulation of epsilon receptors may result in analgesia.

Morphine is a mu-receptor agonist, and pentazocine is a kappa-receptor agonist. Stimulation of mu receptors produces analgesia. Stimulation of kappa receptors produces dysphoria. Morphine has no effect on the kappa receptor and produces less dysphoria than pentazocine. Pentazocine is a kappa receptor agonist that produces dysphoria.

DIF: Comprehension REF: Mechanism of Action (Table 6.2: Opioid Receptors, Effects, and Stimulation by Various Opioids) | pp.

58-59 OBJ:

1

TOP:

NBDHE, 6.0. Pharmacology

4. Oral bioavailability of opioids is primarily limited by a. incomplete absorption. b. first-pass metabolism. c. side effects of nausea and vomiting. d. enterohepatic circulation. e. rapid renal excretion.

ANS: B

The opioids undergo variable first-pass metabolism in the liver or intestinal cell wall, which reduces their bioavailability. Most opioid analgesic agents are absorbed well when taken orally. Opiates need to be available before they cause the side effects of nausea and vomiting. Most opioids are excreted through the kidneys, but this action does not selectively affect their availability after oral administration.

DIF: Comprehension REF: Pharmacokinetics | pp. 58-59 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Which of the following statements is true concerning the pharmacokinetics of opioid analgesics? a. Absorption may occur through mucous membranes of the nose but is not possible

through intact skin. b. The opioids are bound to plasma proteins to varying degrees and distributed throughout the body. c. Given orally, opioids have vastly different durations of action for analgesia, ranging from 1 to almost 12 hours. d. Metabolized opioids are excreted in urine; however, the unchanged drug is not.

ANS: B

Drugs such as opioids are bound reversibly to plasma proteins such as albumin and globulin. The drug that is bound to the protein does not contribute to the intensity of the drug action because only the unbound form is biologically active. Absorption occurs through the mucous membranes of the nose and the intact skin. Given orally, most opioids have a similar duration of action for analgesia—4 to 6 hours. Metabolized opioids and the unchanged drug are excreted in the urine.

DIF: Recall REF: Pharmacokinetics | pp. 58-59 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

6. What do aspirin, acetaminophen, ibuprofen, and codeine have in common? a. They are all antiinflammatory. b. They are all analgesic. c. They all inhibit platelet aggregation. d. They are all antipyretic.

ANS: B

All of them are analgesic. Aspirin and ibuprofen are analgesic, antipyretic, and antiinflammatory, and they inhibit platelet aggregation. Acetaminophen is analgesic and antipyretic. Codeine is analgesic.

DIF: Application REF: Specific Opioids (Opioid Agonists [Table 6.6: Make-Up of Common Opioid Analgesic Products]) | p. 64

OBJ:

4

TOP:

NBDHE, 6.0. Pharmacology

7. Which opioid is commonly used as an antitussive? a. Propoxyphene b. Codeine c. Diphenoxylate d. Pentazocine ANS: B

Opioids work to suppress cough by depressing the cough center in the medulla. The least potent opioids are effective because the dose that produces the antitussive effect is much lower than the dose needed for analgesia, so the least potent opioids, such as codeine, are effective. Propoxyphene is found in Darvocet N-100. Diphenoxylate is in Lomotil, which is used to treat diarrhea. Pentazocine produces central nervous system (CNS) effects not unlike the opioid agonists, including analgesia, sedation, and respiratory depression.

DIF: Application OBJ: 2 8. a. b. c. d.

REF: Pharmacologic Effects (Cough Suppression) | p. 60 TOP: NBDHE, 6.0. Pharmacology

is usually the cause of death with an overdose of opioid analgesics.

Tachycardia Respiratory depression Electrolyte imbalance Cellular necrosis

ANS: B

The opioid analgesic agonists depress the respiratory center in a dose-related manner. This action is usually the cause of death with an overdose. The depression is related to a decrease in the sensitivity of the brainstem to carbon dioxide. Both the rate and the depth of breathing are reduced. Opioids may depress the vasomotor center and stimulate the vagus nerve. Postural hypotension, bradycardia, and even syncope may result with high doses. Opioids can increase the smooth muscle tone in the urinary tract and cause urinary retention; however, this is not the primary cause of death. Cellular necrosis occurs following an injury and is not the predominant cause of death due to an overdose of opioids.

DIF: Comprehension REF: Adverse Reactions (Respiratory Depression) | p. 60 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

9. Which one of the following conditions can be managed or treated with opioids? a. Diarrhea b. Depression c. Infections d. Hypertension ANS: A

The opioids produce constipation by producing a tonic contraction of the gastrointestinal tract. They are used for the treatment of diarrhea. Opioids are not used for the treatment of depression, infections, or hypertension.

DIF: Comprehension

REF: Pharmacologic Effects (Gastrointestinal Effects) | p. 60 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

10. Which of the following conditions is an adverse reaction to the opioids? a. Diarrhea b. Miosis c. CNS excitation d. Hepatotoxicity ANS: B

The opioid analgesics cause miosis (pinpoint pupils), an important sign in diagnosing an opioid overdose or identifying an addict. Opioids produce constipation and CNS sedation. They are not associated with hepatotoxicity.

DIF: Recall REF: Adverse Reactions (Miosis) | p. 61 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

11. The following are conditions for which opioid analgesics should be used with extreme caution or not at

all except which one? a. Head injury b. Nausea c. Respiratory disease d. Hypertension e. Near-term pregnancy ANS: D

Use of opioids is not contraindicated in hypertensive patients. Opioids may stimulate the vagus nerve, which causes bradycardia, a decrease in heart rate. Opioids are contraindicated for patients with head injury because they can increase intracranial pressure, nausea because they can exacerbate nausea, respiratory depression because they are additive, and near-term pregnancy because they are associated with near term fetal respiratory depression.

DIF: Comprehension REF: Adverse Reactions (Table 6.4: Contraindications to and Cautions for the Use of Opioids) | p. 60 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 12. A patient presents with itching and urticaria after codeine administration. This response most likely

represents a a. pharmacologic action of codeine. b. hypersensitivity reaction to codeine. c. placebo effect from receiving codeine. d. reaction unrelated to codeine administration.

ANS: A

The response is a pharmacologic action of codeine. Opioids can stimulate the release of histamine.

Itching and urticaria can result from their administration. Although possible, true opioid allergy is very uncommon. Although a placebo effect may be observed with any drug, this choice is less likely. The reaction is probably related and a pharmacologic action of codeine.

DIF: Comprehension

REF: Adverse Reactions (Histamine Release) | p. 61

OBJ: 2

TOP: NBDHE, 6.0. Pharmacology

13. Which is an advantage of the nonsteroidal antiinflammatory drugs (NSAIDs) over the opioids for the

management of dental pain in an opioid addict? a. They are not addictive. b. They are antitussive. c. They are all useful if the patient is pregnant. d. They cause less fluid retention (edema).

ANS: A

NSAIDs are not addictive, tolerance does not develop, and no withdrawal syndrome can be induced.

NSAIDs should be used to control dental pain in the addict. NSAIDs are not antitussive, some are less useful than others in pregnant women, and NSAIDs can cause decreased renal function, leading to peripheral edema formation.

DIF: Comprehension REF: Adverse Reactions (Addiction) | p. 61 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 14. Tolerance occurs to the following effects of the opioids except which one? a. Miosis b. Analgesia c. Respiratory depression d. Nausea e. Histamine release ANS: A

Tolerance will not develop to miosis and constipation. The rate is related to the strength of the opioid and its frequency of use. It can develop to all of the other listed effects. Tolerance is normally not a problem for those who take opioid analgesics for no more than 1 to 3 days as is the case with managing dental-related pain. Because the duration of use in dentistry is usually short, addiction does not often pose a problem for the dentist.

DIF: Application OBJ: 3

REF: Adverse Reactions (Addiction) | p. 61 TOP: NBDHE, 6.0. Pharmacology

15. Which is the major symptom of opioid overdose? a. Miosis b. Mydriasis c. Urticaria d. Respiratory depression ANS: D

Respiratory depression occurs with opioid overdose, and this symptom can lead to death. Opioids cause miosis, not mydriasis, but the former is not a life-threatening symptom. Urticaria can be caused by opioids, but this is not life threatening in an overdose situation either.

DIF: Recall OBJ: 3

REF: Adverse Reactions (Addiction [Overdose]) | p. 61 TOP: NBDHE, 6.0. Pharmacology

16. Which of the following drugs can be used to treat heroin addiction?

a. b. c. d. e.

Hydromorphone Methadone Naltrexone Both A and C Both B and C

ANS: E

Methadone is used by substituting methadone for heroin and then tapering off or maintaining the addict on oral methadone. Naltrexone, a long-acting opioid antagonist, is used to block the action of usual doses of opioid administered illicitly. Hydromorphone (Dilaudid) is the most potent opioid analgesic on a milligram-for-milligram basis. It is used to treat severe pain. It is a Schedule II narcotic and is not used to treat heroin addiction.

DIF: Comprehension REF: Adverse Reactions (Addiction [Treatment]) | p. 62 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 17. Which of the following opioids is a metabolite of oxycodone that is three times more potent than oral

morphine? a. Codeine b. Hydrocodone c. Hydromorphone d. Oxymorphone ANS: D

Oxymorphone is a metabolite of oxycodone that is available as parenteral short- and long-acting oral dose forms. It is three times more potent than oral morphine and provides adequate pain relief in cancer patients that have been switched from long-acting morphine or oxycodone. Codeine has a relatively weak analgesic action compared with morphine, hydromorphone, hydrocodone, or even oxycodone. Hydrocodone is a synthetic opioid that is metabolized to hydromorphone after oral administration. Hydromorphone is more potent that morphine and better absorbed orally, but it tends to produce similar adverse reactions.

DIF: Recall OBJ: 4

REF: Specific Opioids (Opioid Agonists [Oxymorphone]) | p. 63 TOP: NBDHE, 6.0. Pharmacology

18. Which of the following products is the most commonly used opioid in dentistry? a. Hydrocodone (Vicodin) b. Morphine c. Codeine d. Oxymorphone ANS: C

Codeine is the most commonly used opioid in dentistry. It is used for moderate pain. It is often combined with acetaminophen (Tylenol #3) for oral administration. When codeine is combined with nonopioid analgesics, there is additive analgesic activity. In the combination products, lower doses of each analgesic may be used and there is potential for a reduction in adverse reactions. Hydrocodone, morphine, and oxymorphone are not the most commonly used opioids in dentistry. Hydrocodone (Vicodin) is a synthetic opioid used for moderate pain. Morphine and oxymorphone are used for severe pain.

DIF: Recall OBJ: 4 19. Tylenol #3 contains a. 7.5 b. 15 c. 30 d. 60

REF: Specific Opioids (Opioid Agonists [Codeine]) | p. 63 TOP: NBDHE, 6.0. Pharmacology

mg of codeine.

ANS: C

Tylenol #3 contains 30 mg of codeine. Generally, doses greater than 30 to 60 mg of codeine are poorly tolerated by the patient (too much nausea). In pain studies, showing that 30 mg of codeine is any better than a placebo is difficult, and 60 mg of codeine has an analgesic strength approximately the same as 650 mg of aspirin, 650 mg of acetaminophen, or 200 mg of ibuprofen. Tylenol #1 contains 7.5 mg of codeine, Tylenol #2 contains 15 mg of codeine, and Tylenol #4 contains 60 mg of codeine.

DIF: Recall REF: Pharmacokinetics (Table 6.3: Selected Opioid Analgesics by Dosing Interval, Usual Doses, and Schedule) | p. 60 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 20. Which of the following opioids is used primarily in the treatment of opioid addiction? a. Propoxyphene b. Meperidine c. Hydromorphone d. Methadone ANS: D

Methadone is used either to withdraw the patient gradually or for methadone maintenance. Because it has a longer duration of action, withdrawal from methadone is easier than from heroin. Because it is an opioid analgesic, however, the risk for dependence still exists. Propoxyphene is in Darvocet N-100; its analgesic efficacy has been questioned, and it is certainly no more efficacious than two tablets of aspirin or acetaminophen. Meperidine is intended for the acute management of moderate-to-severe pain. Hydromorphone is reserved for the management of severe pain.

DIF: Recall OBJ: 4

REF: Specific Opioids (Opioid Agonists [Methadone]) | pp. 63-65 TOP: NBDHE, 6.0. Pharmacology

21. Which of the following agents is a potent, short-acting, parenterally administered opioid that is

commonly used during general anesthesia? a. Dynorphin b. Hydromorphone c. Nalmefene d. Fentanyl e. Tramadol ANS: D

Fentanyl is a short-acting, parenterally administered agonist opioid analgesic that is used perioperatively or during general anesthesia. Dynorphin is an endogenous opioid. Hydromorphone is reserved for the management of severe pain. Nalmefene is an opioid antagonist. Tramadol is an orally administered nonopioid with weak analgesic activity.

DIF: Recall OBJ: 4

REF: Specific Opioids (Opioid Agonists [Fentanyl Family]) | p. 65 TOP: NBDHE, 6.0. Pharmacology

22. Which opioid analgesic is most likely to produce dysphoria? a. Meperidine b. Codeine c. Pentazocine d. Oxycodone e. Hydrocodone ANS: C

Of the agents listed, pentazocine has the greatest propensity for causing dysphoric reactions. It is a mixed agonist-antagonist opioid, and produces CNS effects not unlike the opioid agonists, including analgesia, sedation, and respiratory depression. The type of analgesia it produces is somewhat different from that produced by the agonist opioids. This may be a result of its agonist action on kappa and delta receptors and its antagonist action at the mu receptor. References differ whether sigma or delta opioid receptors may be responsible for the dysphoria. Meperidine, codeine, oxycodone, and hydrocodone are opioid agonists. They are not the primary opioid associated with dysphoria.

DIF: Comprehension REF: Mechanism of Action | p. 58 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 23. How does adding naloxone to pentazocine reduce the addiction potential of orally administered

pentazocine? a. Naloxone is an opioid agonist that is effective orally but not parenterally. b. Naloxone is an opioid agonist that is effective parenterally but not orally. c. Naloxone is an opioid antagonist that is effective orally but not parenterally. d. Naloxone is an opioid antagonist that is effective parenterally but not orally. e. Naloxone is a nonsteroidal antiinflammatory.

ANS: D

Naloxone is a pure opioid antagonist. It is effective parenterally but not orally because it is inactivated.

If the tablet is taken by the oral route, the naloxone will not affect the analgesic potency of the pentazocine. If the contents of the tablet are injected parenterally, the naloxone will be active and will counteract the effects of the pentazocine. Naloxone is not an opioid agonist and it is inactivated when taken orally. It is not a nonsteroidal anti-inflammatory drug.

DIF: Comprehension REF: Specific Opioids (Mixed Opioids [Agonist-Antagonist Opioids]) | p. 65 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 24. Which of the following agents is the only mixed opioid available for oral use? a. Dezocine b. Nalbuphine c. Pentazocine d. Butorphanol ANS: C

Pentazocine is the only mixed opioid available for oral use. Butorphanol, available as a nasal spray, is also in this group. Dezocine, nalbuphine, and butorphanol are parenterally available agonistantagonists. Dezocine has agonist action at the kappa (k) receptor and antagonist action at the mu (m) receptor.

DIF: Recall OBJ: 5

REF: Specific Opioids (Mixed Opioids [Agonist-Antagonist Opioids]) | p. 65 TOP: NBDHE, 6.0. Pharmacology

25. Which of the following choices is the drug of choice to treat a patient who has taken an overdose of an

opioid? a. 2-pralidoxime b. Naloxone c. N-acetylcysteine d. Activated charcoal e. Methadone ANS: B

Naloxone is an opioid antagonist that will block the therapeutic and toxic actions of opioids; the others are not. Pralidoxime is used to treat an overdose of cholinesterase inhibitors such as insecticides or organophosphates. Acetylcysteine is a mucolytic used to loosen secretions in pulmonary diseases.

Activated charcoal is used for the emergency treatment of certain poisonings. Methadone is an opioid used in treatment of addiction, but will exacerbate symptoms of an opioid overdose.

DIF: Recall OBJ: 5

REF: Specific Opioids (Opioid Antagonists [Naloxone]) | p. 65 TOP: NBDHE, 6.0. Pharmacology

26. Tapentadol is an oral opioid receptor a. agonist; norepinephrine b. agonist; acetylcholine c. antagonist; norepinephrine d. antagonist; acetylcholine

and a

reuptake inhibitor.

ANS: A

Tapentadol is classified as a full opioid agonist norepinephrine reuptake inhibitor. It has oral administration in an extended-release formula that appears to be similar in efficacy to extended-release oxycodone for osteoarthritis and lower back pain. The drug’s labeling carries a warning for the possibility of serotonergic syndrome when used with serotonergic drugs. Tapentadol is not an opioid antagonist as are naloxone, nalmefene, and naltrexone. It does not prevent the reuptake of acetylcholine.

DIF: Recall OBJ: 6

REF: Specific Opioids (Full Agonist/Reuptake Inhibitors [Tapentadol]) | p. 66 TOP: NBDHE, 6.0. Pharmacology

27. The following statements are true of tramadol except which one? a. It binds to mu opioid receptors. b. It inhibits reuptake of serotonin and norepinephrine. c. It modifies ascending pain pathways. d. It causes mydriasis. e. Its analgesic efficacy is equivalent to that of codeine.

ANS: D

Mydriasis is pupillary dilation. As in opioids, tramadol causes miosis, or pinpoint pupils. Tramadol does in fact bind mu opioid receptors, inhibits reuptake of serotonin and norepinephrine, and modifies ascending pain pathways. Its analgesic efficacy is equivalent to that of codeine.

DIF: Comprehension REF: Specific Opioids (Full Agonist/Reuptake Inhibitors [Tramadol]) | p. 66 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 28. Dentists prescribed about a. 2 b. 12 c. 22 d. 32 e. 42

% of all immediate-release opioids prescribed in the United States.

ANS: B

Dentists are second only to family practice physicians as the practitioners prescribing the highest number of immediate-release opioids in the United States. They accounted for 12.2% of all opioid prescribed. Analgesics are prescribed at a rate second only to antibiotics in a dental practice. The other choices do not correctly represent the percentage of opioids prescribed by dentists in the United States.

DIF: Recall REF: Dental Use of Opioids | p. 66 TOP: NBDHE, 6.0. Pharmacology

OBJ: 7

29. Which of the following types of pain medications is the best choice for management of most dental

pain? a. Antidepressants b. Nonsteroidal antiinflammatory drugs (NSAIDs) c. Aspirin d. Acetaminophen ANS: B

The advent of the NSAIDs has produced a change in the use of the opioids in dental practice. Most dental pain can be better managed by the use of NSAIDs. In the patient in whom NSAIDs are contraindicated, the dentist has a wide range of opioids from which to choose. Antidepressants are not the best choice for management of most dental pain although low doses of antidepressants may be used along with NSAIDs and muscle relaxants to treat TMD. Aspirin and acetaminophen are not the first choice for dental pain.

DIF: Comprehension REF: Dental Use of Opioids | p. 66 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 30. Which opioid analgesic is a Schedule II controlled substance? a. Pentazocine (in Talwin HX) b. Hydrocodone (in Vicodin, Lortab, Lorcet) c. Codeine (in Tylenol #3, Empirin #3) d. Dihydrocodeine (in Synalgos-DC) ANS: B

Hydrocodone was recategorized in 2014 as a Schedule II controlled substance due to diversion.

Pentazocine is Schedule IV. Codeine and dihydrocodeine are Schedule III. DIF: Comprehension REF: Pharmacokinetics (Table 6.3: Selected Opioid Analgesics by Dosing Interval, Usual Doses, and Schedule) | p. 60 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 31. Codeine may cause nausea and vomiting by activating the chemoreceptor trigger zone in the a. thalamus. b. hypothalamus. c. medulla. d. frontal lobe.

ANS: C

The medulla controls vital autonomic functions. Codeine can cause nausea and vomiting by acting on the medulla in the brainstem. The thalamus controls reciprocal connections with the cerebral cortex.

The hypothalamus functions in integrative control of autonomic functions. Both the thalamus and hypothalamus are part of the diencephalon of the brain. The frontal lobe controls voluntary motor functions and is part of the cerebral hemispheres.

DIF: Recall OBJ: 2

REF: Adverse Reactions (Nausea and Emesis) | p. 61 TOP: NBDHE, 6.0. Pharmacology

32. Which opioid agonist provides a strength of analgesic action between codeine and morphine? a. Acetaminophen b. Aspirin c. Oxycodone (in Percodan, Percocet) d. Dihydrocodone (in Synalgos-DC) ANS: C

Oxycodone is alone or combined with either aspirin (in Percodan) or acetaminophen (in Percocet and Tylox). It bridges the gap between codeine and morphine in terms of strength of analgesic action.

These agents work at two different levels on pain and produce an additive analgesic effect. In combination products, lower doses of each analgesic may be used, and a potential exists for a reduction in adverse reactions. Acetaminophen and aspirin are nonopioid analgesics. Dihydrocodone, like codeine, is a Schedule III controlled substance.

DIF: Comprehension REF: Specific Opioids (Opioid Agonists [Oxycodone]) | p. 63 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

33. Children should not receive codeine after a tonsillectomy due to an increased risk for a. central nervous system depression. b. respiratory depression. c. postural hypotension. d. constipation.

ANS: B

Children less than 18 years of age post tonsillectomy or adenoidectomy should not receive codeine or tramadol due to an increased risk for respiratory depression. Opioids may produce CNS stimulation on occasion, rather than depression. Postural hypotension may result with the use of high doses of opioids; however, it is not a contraindication for their use in children. Opioids cause constipation, but it is not a contraindication for their use in children.

DIF: Recall OBJ: 2

REF: Adverse Reactions (Respiratory Depression) | p. 61 TOP: NBDHE, 6.0. Pharmacology

34. What is the primary advantage of oxycodone ER over previous formulations? a. It is formulated to help deter substance abuse. b. It is not a controlled substance. c. It is a liquid for administration to patients who have difficulty swallowing. d. It is a Schedule III narcotic, so it is easier to prescribe.

ANS: A

These new formulations have one or more properties that make intentional nontherapeutic use more difficult, less attractive, and less rewarding. Oxycodone ER (Oxycontin) is a Schedule II controlled substance. The tablets resist crushing and breaking. They form a viscous gel when dissolved to discourage abuse.

DIF: Comprehension REF: Specific Opioids (Opioid Agonists [Abuse Deterrent Opioids]) | p. 65 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 35. Each of the following contains naltrexone except one. Which is the exception? a. Embeda b. Targiniq ER c. Xtampza d. Troxyca ANS: C

Xtampza is one of the abuse-deterrent opioid analgesics. The strategy employed by Xtampza is that it is composed of microspheres that resist the effect of crushing and chewing. The contents of melted or dissolved capsules are difficult to inject. All of these are abuse-deterrent opioid analgesics. Embeda is a combination of morphine ER/Naltrexone, and Targiniq ER and Troxyca are combinations of oxycodone ER/Naltrexone.

DIF: Comprehension REF: Specific Opioids (Opioid Agonists [Abuse Deterrent Opioids]) | p. 65 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 36. Which is true regarding naloxone access laws? a. Federal law restricts the use of naloxone to emergency medical services (EMS)

teams. b. The law requires criminal prosecution for persons who need to use of naloxone. c. Many states have passed laws making naloxone available to first responders,

family members, and close friends of persons taking or abusing opioids. d. Naloxone will potentiate effects of a narcotic and should be used strictly to prevent

withdrawal.

ANS: C

Most states have granted standing prescription orders that authorize nonmedical personnel to administer naloxone. Naloxone is available in most all pharmacies and is available to anyone that requests it. Many laws grant civil and criminal immunity to laypeople who carry or administer naloxone, to health care professionals who prescribe or dispense it to laypeople, and to persons who call for emergency medical services in good faith to reverse an overdose. There is no federal law that restricts the use of naloxone to EMS teams. In fact, several state departments of health have issued standing prescription orders to all pharmacies for naloxone to treat opioid overdose. Laws also provide for civil and criminal immunity to the person who is being treated for an overdose. Naloxone is an opioid reversal agent and will not potentiate the effect of a narcotic.

DIF: Comprehension REF: Specific Opioids (Opioid Antagonists [Naloxone]) | p. 65 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Which of the following are classified as mixed opioid? (Select all that apply.) a. Morphine b. Pentazocine c. Naloxone d. Buprenorphine ANS: B, D

Pentazocine is a mixed opioid classified as an agonist antagonist. Buprenorphine is a mixed opioid that is classified as a partial agonist. Morphine is an opioid agonist. Naloxone is a morphine antagonist.

DIF: Application REF: Classification (Table 6.1: Classification of the Opioids by Receptor Action) | p. 59 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Morphine is stronger than oxycodone.

ANS: T

Morphine has greater efficacy (analgesic power) than oxycodone.

DIF: Recall REF: Pharmacokinetics (Table 6.3: Selected Opioid Analgesics by Dosing Interval, Usual Doses, and Schedule) | p. 60 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 2. Codeine activates the chemoreceptor trigger zone.

ANS: T

Codeine can cause nausea and vomiting by acting on this medullary structure.

DIF: Recall

REF: Adverse Reactions (Nausea and Emesis) | p. 61

OBJ: 2

TOP: NBDHE, 6.0. Pharmacology

3. Combining an opioid with a nonopioid analgesic produces an additive analgesic effect with fewer

adverse reactions.

ANS: T

These agents work at two different levels on pain and produce an additive analgesic effect. In combination products, lower doses of each analgesic may be used, and a potential exists for a reduction in adverse reactions.

DIF: Recall OBJ: 4

REF: Specific Opioids (Opioid Agonists [Oxycodone]) | p. 63 TOP: NBDHE, 6.0. Pharmacology

4. A patient who feels nauseated after taking codeine is allergic to it.

ANS: F

Nausea is a normal pharmacologic action of codeine on the chemoreceptor trigger zone in the brain.

DIF: Recall OBJ: 2

REF: Adverse Reactions (Nausea and Emesis) | p. 61 TOP: NBDHE, 6.0. Pharmacology

5. Opioids are the first choice for the treatment of chronic pain, such as temporomandibular joint and

muscle disorders.

ANS: F

Because of their dependence liability, opioids should not be the first choice for patients with chronic pain (unless they are terminally ill). The dentist should initiate therapy with an NSAID. Opioids should be considered if this fails. Only those dentists that are comfortable with prescribing chronic opioid therapy should treat patients with chronic orofacial pain.

DIF: Recall OBJ: 7

REF: Chronic Dental Pain and Opioid Use | p. 67 TOP: NBDHE, 6.0. Pharmacology

Chapter 07: Antiinfective Agents Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Dental caries is caused by an infection with a. Porphyromonas gingivalis. b. Eikenella corrodens. c. Streptococcus mutans. d. Fusobacterium.

ANS: C

Dental caries is produced by Streptococcus mutans. It is the first important dental infection of the newly erupting teeth of the young patient. The treatment of choice is prevention and involves the use of fluoridated water, local physical removal of bacterial plaque biofilm from teeth on a regular basis, and appropriately placed sealants. Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Eikenella corrodens, Fusobacterium spp., and Campylobacter rectus are all periodontal microbes.

DIF: Recall REF: Introduction | p. 68 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. Which of the following choices is the dental hygienist’s biggest dental problem in the adult patient? a. Caries b. Periodontal disease c. Localized dental infection d. Systemic dental infection ANS: B

Periodontal disease is the dental hygienist’s biggest dental problem in the adult patient. Current research suggests that periodontal disease may be associated with coronary heart disease. With an increase in knowledge about antiinfective agents, the dental hygienist and dentist will be better able to understand and properly administer the appropriate drug therapy. Use of fluoridated water, local physical removal of bacterial plaque biofilm from teeth on a regular basis, and sealants have reduced the rate of caries. While it certainly is true that local and systemic dental infections are of great concern, they are not the biggest problem in an adult patient for a dental hygienist to manage.

DIF: Recall REF: Introduction | p. 68 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. If an infection is just beginning, the organisms most likely to be present are a. gram-positive cocci. b. gram-negative cocci. c. gram-positive anaerobes. d. gram-negative anaerobes.

ANS: A

Gram-positive cocci are most likely to present if the infection is just beginning. After a short time, the gram-positive infection begins to include a variety of both gram-positive and gram-negative anaerobic organisms. With additional time and no treatment, the infection progresses until it consists of predominantly anaerobic flora. Gram-negative and/or anaerobic organisms are not the earliest constituents of a dental infection.

DIF: Comprehension REF: Evolution of a Dental Infection | p. 68 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. Which of the following agents is the drug of choice for an early dental infection unless the patient is

allergic to it? a. Erythromycin b. Clindamycin c. Penicillin

d. Metronidazole ANS: C

Penicillin is the drug of choice unless the patient is allergic to it. Amoxicillin is most often used because it is less irritating to the stomach than other drugs and can be taken with food or milk. In patients allergic to penicillin, alternatives might include erythromycin or clindamycin. When the infection is at the mixed stage, agents effective against either gram-positive or anaerobic organisms may be successful. Metronidazole is effective for anaerobic organisms.

DIF: Comprehension REF: Evolution of a Dental Infection | p. 68 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Which of the following antibiotics is associated with pseudomembranous colitis? a. Penicillin b. Erythromycin c. Clindamycin d. Metronidazole ANS: C

Clindamycin is associated with pseudomembranous colitis (PMC), also known as antibiotic-associated colitis (AAC). It is characterized by severe, persistent diarrhea and the passage of blood and mucus. It is caused by a toxin produced by the bacterium Clostridium difficile. It is associated with other antibiotics in addition to clindamycin such as tetracycline, ampicillin, and the cephalosporins.

Pseudomembranous colitis has historically been linked with an antibiotic other than penicillin, erythromycin, or metronidazole. It now is known to occur not only with a wide variety of antiinfective agents including cephalosporins and amoxicillin, but also in the absence of any antimicrobial agents.

DIF: Comprehension REF: Clindamycin (Adverse Reactions [Gastrointestinal Effects]) | p. 79 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 6. An agent is a substance that destroys or suppresses the growth or multiplication of bacteria. a. antiinfective b. antibacterial c. antibiotic d. antimicrobial ANS: B

An antibacterial is a broader category than an antibiotic. There are antibacterial agents that are not antibiotics that can act against bacterial infections. Historically, an antibiotic was a chemical substance produced by a microorganism that has the capacity, in dilute solutions, to destroy or suppress the growth or multiplication of another organism or to suppress its action. Although many early antibiotics were derived from natural sources, most are synthesized in laboratories. This difference is largely ignored in general conversation, and antiinfectives and antibacterial agents are often called antibiotics.

DIF: Recall REF: Definitions | p. 69 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

7. Which of the following antiinfective agents is bacteriostatic, but may be bactericidal at higher dose

levels?

a. b. c. d. e.

Cephalosporins Metronidazole Penicillins Erythromycin Vancomycin

ANS: D

Clindamycin and macrolides, including erythromycin, clarithromycin, and azithromycin, are bacteriostatic, but may be bactericidal against some organisms at higher blood levels. Tetracyclines— chloramphenicol, spectinomycin, sulfonamides, and trimethoprim—are all bacteriostatic.

Aminoglycosides—bacitracin, cephalosporins, metronidazole, penicillins, polymyxin, quinolones, rifampin, and vancomycin—are all bactericidal antiinfective agents.

DIF: Application REF: Definitions (Box 7.2: Classification of Antiinfective Agents: Bactericidal or Bacteriostatic) | p. 69 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 8. The disease-producing power of the microorganism is called a. resistance. b. superinfection. c. infection. d. virulence.

ANS: D

Virulence is the disease-producing power of the microorganism. Resistance is the ability of an organism to be immune to the effects of an antiinfective agent. Superinfection is an opportunistic infection that arises as a consequence of treatment. Infection is an unchecked increase in the number of pathogenic bacteria in the body.

DIF: Recall REF: Infection | p. 69 TOP: NBDHE, 6.0. Pharmacology 9. Superinfection is more often caused by a. b. c. d.

OBJ: 1

-spectrum antibiotics and increases when taken for a

time period. narrow; shorter narrow; longer broad; shorter broad; longer

ANS: D

Superinfection is more often caused by broad-spectrum antibiotics and increases when taken for a longer time period. A reduction in the number of gram-positive and gram-negative bacteria may allow the overgrowth of the fungus Candida albicans. A broad-spectrum antibiotic is more likely to alter the nature of the microbes. A sensitivity test can determine whether the organisms are sensitive or resistant to certain test antibiotics and assist in determining which antibiotic to use in difficult infections.

DIF: Application REF: General Adverse Reactions and Disadvantages Associated with Antiinfective Agents (Superinfection (Suprainfection)) | p. 70 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

10. The possibility of superinfection can be minimized by use of the a. b. c. d.

specific antiinfective agent, the

effective course of therapy, and adequate doses. least; shortest least; longest most; shortest most; longest

ANS: C

The most specific antiinfective agent and the shortest course of therapy are best. The wider the spectrum of the antiinfective agent and the longer the agent is administered, the greater the chance of superinfection.

DIF: Recall REF: General Adverse Reactions and Disadvantages Associated with Antiinfective Agents (Superinfection (Suprainfection)) | p. 70 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 11. Which of the following statements is true concerning infection and host resistance? a. Host resistance should be considered as having both local and systemic b. c. d. e.

components.

If a patient has diabetes mellitus it can reduce the resistance to an infection.

Drugs such as steroids are capable of enhancing a patient’s immune response.

Both A and B. Both B and C.

ANS: D

Host resistance should be considered as having both local and systemic components. Diseases such as acquired immunodeficiency syndrome (AIDS) and IDDM may reduce a patient’s immunity and increase the chance of an infection. Drugs such as steroids are capable of reducing a patient’s immunity and increase the chance of infection.

DIF: Comprehension REF: Infection | p. 69 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 12. The misuse of antibiotics has contributed to antibiotic resistance. The solution to reducing the

incidence of antibiotic-resistant bacteria is to write more prescriptions for antibiotics. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

The number of antibiotic-resistant bacteria has increased dramatically over the past 10 years, and many bacterial infections are becoming resistant to some of the most commonly prescribed antibiotics. The solution is to write fewer, but more appropriate prescriptions. The correct antibiotic, with the correct dose and duration, should be prescribed.

DIF: Comprehension REF: Resistance | p. 70 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 13. Which of the following statements is true concerning antibiotic resistance?

a. Natural resistance occurs when an organism that was previously sensitive to an

antimicrobial agent develops resistance. b. An increase in the use of an antibiotic in a given population decreases the

proportion of resistant organisms in that population. c. Bacterial resistance can occur by the transfer of deoxyribonucleic acid (DNA)

genetic material from one organism to another. d. The transfer of genetic material from one organism to another may only occur among organism of the same species.

ANS: C

Bacterial resistance can occur by the transfer of DNA genetic material from one organism to another via transduction, transformation, or bacterial conjugation. Natural resistance occurs when an organism has always been resistant to an antimicrobial agent because of the bacteria’s normal properties, such as lipid structure in the cell wall. Acquired resistance occurs when an organism that was previously sensitive to an antimicrobial agent develops resistance. An increase in the use of an antibiotic in a given population increases the proportion of resistant organisms in that population. The transfer of genetic material from one organism to another may occur among very different microorganisms, including transfer from nonpathogenic bacteria to pathogenic bacteria.

DIF: Comprehension REF: Resistance | p. 70 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 14. Which of the following periodontal diseases is usually not treated with antimicrobials? a. Periodontal abscess b. Localized juvenile periodontitis c. Adult periodontitis d. Rapidly advancing periodontitis ANS: C

No antimicrobial agents are usually required for treatment of adult periodontitis or acute necrotizing ulcerative gingivitis. The drug of choice for periodontal abscess is penicillin VK, with tetracycline as an alternative. For localized juvenile periodontitis, either doxycycline or tetracycline are the drugs of choice with amoxicillin + metronidazole, or Augmentin as alternative drugs. Rapidly advancing periodontitis (RAP) may be treated with doxycycline, tetracycline, or metronidazole. Amoxicillin + metronidazole are the alternative drugs for treating RAP. DIF: Comprehension REF: Indications for Antimicrobial Agents (Therapeutic Indications [Table 7.1: Antimicrobial Use in Dentistry]) | pp. 70-71 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 15. Superinfection describes a(n) a. nonsystemic, superficial infection. b. exaggerated infection caused by treating a resistant pathogen. c. opportunistic infection that arises as a consequence of treatment. d. infection by multiple pathogens.

ANS: C

When antiinfectives disturb the normal flora of the body, the emergence of organisms unaffected by or resistant to the antibiotic used can occur. Superinfection can be superficial or nonsuperficial. It is an infection that does not require treatment of a resistant pathogen to occur. Superinfection can be an infection by one or more pathogens.

DIF: Application REF: General Adverse Reactions and Disadvantages Associated with Antiinfective Agents (Superinfection (Suprainfection)) | p. 70 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 16. Antiinfective agents can potentiate the effect of oral anticoagulants by interfering with the production

of vitamin a. A. b. D. c. E. d. K. ANS: D

Oral anticoagulants are vitamin K inhibitors; thus, interference with the production of vitamin K could increase the anticoagulant effect. Bacterial flora in the intestine produces most of the vitamin K in human bodies. Antiinfective agents reduce the bacterial flora that produce vitamin K. With the vitamin K reduced, the oral anticoagulant’s effect is increased. Vitamins A, D, E, and K are fat-soluble vitamins. Vitamin A is necessary for normal growth and for maintaining the health and integrity of certain epithelial tissues. Vitamin D refers to both vitamin D 2, which is found in plants, and vitamin D3, which is produced in the skin of mammals by sunlight. There are eight naturally occurring tocopherols with vitamin E activity. Alpha tocopherol is the most active. It is found in wheat, sunflower, cottonseed, and olive oils.

DIF: Comprehension REF: General Adverse Reactions and Disadvantages Associated with Antiinfective Agents (Superinfection (Suprainfection) [Oral Anticoagulants]) | p. 72 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 17. a. b. c. d.

has the highest incidence of gastrointestinal complaints of any of the antibiotics.

Penicillin Erythromycin Clindamycin Cephalosporin

ANS: B

Erythromycin has the highest incidence of gastrointestinal complaints. The penicillins and cephalosporins are associated with allergic reactions rather than gastrointestinal complaints. More serious gastrointestinal complaints, such as pseudomembranous colitis, which has been historically linked with clindamycin, are now known to occur not only with a wide variety of antiinfective agents, but also in the absence of any antimicrobial agents.

DIF: Recall REF: General Adverse Reactions and Disadvantages Associated with Antiinfective Agents (Gastrointestinal Complaints) | p. 72 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

18. Which of the following antibiotics are not associated with any teratogenicity and are often used in

pregnant women? a. Penicillin b. Tetracyclines c. Erythromycin d. Metronidazole e. Both A and C ANS: E

Penicillin and erythromycin have not been associated with teratogenicity and are often used in pregnant women. Tetracyclines are contraindicated during pregnancy because of their effect on developing teeth and skeleton. Metronidazole is not usually used during pregnancy, but exceptions exist.

DIF: Comprehension REF: General Adverse Reactions and Disadvantages Associated with Antiinfective Agents (Pregnancy Considerations) | p. 72 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 19. Which of the following statements is true concerning the pharmacokinetics of penicillin? a. Penicillin may be administered orally, parenterally, or topically. b. Penicillin G is better absorbed orally than penicillin V; thus, penicillin G is used

for administration of oral penicillin. c. Penicillin V and amoxicillin can be taken without regard to meals. d. Penicillin does not cross the placenta and will not appear in breast milk.

ANS: C

The highest blood levels are obtained if the patient takes the penicillin orally at least 1 hour before or 2 hours after meals, but penicillin V and amoxicillin can be taken without regard to meals. Penicillin can be administered either orally or parenterally, but should not be applied topically because its allergenicity is greatest by that route. Penicillin V is better absorbed orally than penicillin G; thus, penicillin V is used for administration of oral penicillin. Penicillin crosses the placenta and appears in breast milk.

DIF: Comprehension REF: Penicillin Varieties (Pharmacokinetics) | p. 73 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 20. Penicillinase inactivates the penicillin moiety by a. sublimation. b. desiccation. c. cleaving the -lactam ring. d. cleaving the S-containing thiazolidine ring.

ANS: C

The penicillins belong to the group of antibiotics known as -lactam antibiotics. They are so named because the -lactam ring is common to the molecular structure of all antibiotics in this group.

Penicillinase inactivates the moiety by cleaving the -lactam ring. The other choices represent substances that do not cleave the -lactam ring. Sublimation occurs when a substance goes from solid directly to gas without becoming a liquid. Desiccation is loss of moisture. The thiazolidine ring is part of the structure of penicillin. The -lactam ring is fused to the five-member, S-containing thiazolidine ring.

DIF: Recall OBJ: 4

REF: Penicillin Varieties (Resistance) | p. 73 TOP: NBDHE, 6.0. Pharmacology

21. Which of the following agents allows the use of amoxicillin to treat penicillinase-producing

organisms? a. Clavulanic acid b. Divalent cations c. Corticosteroids d. Disulfiram ANS: A

Clavulanic acid serves as an inhibitor, which allows the use of amoxicillin to treat penicillinaseproducing organisms. The other choices are not added to amoxicillin in order to treat penicillinaseproducing organisms. A divalent cation is an atom that is missing two electrons. They reduce the intestinal absorption of tetracyclines by forming non-absorbable chelates of tetracycline with calcium, for example. Corticosteroids are used to reduce inflammation. Disulfiram is a drug used to treat persons with alcohol problems.

DIF: Recall OBJ: 4

REF: Penicillin Varieties (Resistance) | p. 73 TOP: NBDHE, 6.0. Pharmacology

22. Some studies indicate that a. 0.05 to 0.10 b. 0.5 to 1 c. 5 to 10 d. 20 to 25

% of patients receiving penicillin will have an anaphylactic reaction.

ANS: A

It is estimated that an anaphylactic reaction occurs in up to 0.05% of penicillin-treated patients, with a mortality of 5% of 10%. Any history of an allergic reaction to penicillin contraindicates its use. Some studies indicate that 5% to 10% of patients receiving penicillin will have an allergic reaction. Allergic reactions to oral penicillin are less common than with parenteral penicillin. The other choices do not correctly express the results indicated by studies regarding the frequency of allergic reaction to the administration of penicillin.

DIF: Recall REF: Penicillin Varieties (Adverse Reactions [Allergy and Hypersensitivity]) | p. 74 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 23. Which of the following statements is true regarding penicillin allergy?

a. Allergic reactions with oral penicillin are more common than with parenteral

penicillin.

b. Anaphylactic reactions are more frequent in patients pretreated with -blockers

and subsequently given oral penicillin. c. The treatment of anaphylaxis caused by penicillin is the immediate administration

of corticosteroids. d. Estimates indicate that 10,000 to 30,000 deaths occur annually in the United States

because of an allergic reaction to penicillin.

ANS: B

Anaphylactic reactions are more frequent in patients pretreated with -blockers and subsequently given oral penicillin. Anaphylactic reactions in these patients have been reported to be difficult to treat.

Allergic reactions with parenteral penicillin are more common than with oral penicillin. The treatment of anaphylaxis caused by penicillin is the immediate administration of parenteral epinephrine. An estimated 100 to 300 deaths occur annually in the United States because of an allergic reaction to penicillin.

DIF: Comprehension REF: Penicillin Varieties (Adverse Reactions [Allergy and Hypersensitivity]) | p. 74 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 24. Which of the following salts of penicillin G produces the most rapid and highest blood level? a. Potassium salt given intravenously b. Potassium salt given intramuscularly c. Benzathine salt given intramuscularly d. Procaine salt intramuscularly ANS: A

The potassium salt given intravenously produces the most rapid and highest blood level. The penicillin’s duration of action is inversely proportional to the solubility of the penicillin form: the least soluble is the longest acting. The benzathine salt given intramuscularly produces the lowest and most sustained blood level. The potassium and procaine salts, given intramuscularly, produce intermediate blood levels and durations of action.

DIF: Comprehension REF: Penicillin Varieties (Specific Penicillins [Penicillin G]) | p. 74 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 25. The usual adult dose of penicillin V for treatment of an infection is a. 250 mg twice a day (bid). b. 250 mg four times a day (qid). c. 250 to 500 mg twice a day (bid). d. 250 to 500 mg four times a day (qid).

ANS: D

The usual adult dose is 250 to 500 mg qid for the treatment of an infection for a minimum of 5 days and preferably for 7 to 10 days. The usual adult dose of penicillin for treating an infection is not 125 mg. Penicillin is not usually administered twice a day (bid) in order to treat an infection.

DIF: Comprehension

REF: Penicillin Varieties (Specific Penicillins [Penicillin V]) | p. 74 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 26. Which of the following statements is true regarding penicillinase-resistant penicillins? a. Penicillinase-resistant penicillins should be reserved for use against only

penicillinase-producing staphylococci. b. Penicillinase-resistant penicillins are more effective against penicillin G-sensitive

organisms when compared with penicillin G. c. Penicillinase-resistant penicillins produce fewer side effects when compared with penicillin G. d. Patients allergic to penicillin are not also allergic to the penicillinase-resistant penicillins.

ANS: A

Penicillinase-resistant penicillins should be reserved for use against only penicillinase-producing staphylococci. The penicillinase-resistant penicillins are less effective against penicillin G-sensitive organisms when compared with penicillin G. Penicillinase-resistant penicillins produce more side effects when compared with penicillin G. Patients allergic to penicillin are also allergic to the penicillinase-resistant penicillins.

DIF: Comprehension REF: Penicillin Varieties (Specific Penicillins [Penicillinase-Resistant Penicillins]) | p. 74 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 27. Which drug should be used before oral prophylaxis prior to dental treatment for a patient who has

rheumatic heart disease with no known drug allergies? a. Amoxicillin b. Tetracycline c. Clindamycin d. Erythromycin e. None of the above ANS: E

The current guidelines for prevention of infective endocarditis from the American Heart Association (2008) do not recommend oral immunoprophylaxis before dental treatment for a patient with a history of rheumatic heart disease. Specific indications for oral immunoprophylaxis may be found on the American Heart Association Website. A history of rheumatic heart disease is no longer considered an indication for oral immunoprophylaxis. If the patient does have one of the currently recommended indications amoxicillin is the standard treatment of choice if no complicating factors are present, such as allergy to penicillins. Tetracycline is never indicated for infective endocarditis prophylaxis just before dental procedures because it is likely to produce bacteremia. Clindamycin is a recommended alternative to amoxicillin if penicillin allergies exist, and erythromycin analogues azithromycin and clarithromycin are also good alternatives.

DIF: Application REF: Antibiotic Prophylaxis Used in Dentistry (Prevention of Infective Endocarditis [Cardiac Conditions] [Box 7.6: Cardiac Conditions Associated with the Highest Risk of Adverse Outcomes from Endocarditis]) | p.

87 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 28.

is the drug of choice for prophylaxis to prevent bacterial endocarditis before a dental procedure.

a. b. c. d.

Penicillin G Penicillin V Ampicillin Amoxicillin

ANS: D

Amoxicillin is the drug of choice. Amoxicillin is also used to treat upper respiratory tract infections, urinary tract infections, and meningitis. Otitis media in children is often treated with amoxicillin. It has had some use in the management of certain periodontal conditions. Penicillin G, penicillin V, and ampicillin are not used for prophylaxis to prevent bacterial endocarditis prior to a dental procedure.

DIF: Comprehension REF: Penicillin Varieties (Specific Penicillins [Ampicillins]) | p. 74 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 29. Which of the following antibiotics is available mixed with clavulanic acid? a. Ampicillin b. Amoxicillin c. Carbenicillin d. Azithromycin ANS: B

Augmentin is amoxicillin mixed with clavulanic acid. Clavulanic acid combines with and inhibits the -lactamases produced by bacteria. Therefore the amoxicillin is protected from enzymatic inactivation.

This combination can be taken with penicillinase-producing organisms. It has had some use in the management of certain periodontal conditions. The other antibiotics are not mixed with clavulanic acid.

DIF: Comprehension REF: Penicillin Varieties (Specific Penicillins [Ampicillins]) | pp. 74-75 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 30. Clavulanic acid is a. a bacteriostatic antibiotic. b. a bactericidal antibiotic. c. a -lactamase inhibitor. d. Both A and C. e. Both B and C. ANS: C

Clavulanic acid is a penicillinase (-lactamase) inhibitor. It inhibits the ability of bacteria to break down -lactam-containing antibiotics. Clavulanic acid is not an antibiotic.

DIF: Comprehension REF: Penicillin Varieties (Specific Penicillins [Ampicillins]) | p. 75 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 31. Clavulanic acid is used to fight infections with which of the following resistance mechanisms? a. Decreased permeability to the agent b. Production of drug-inactivating enzymes

c. Alteration in the site of action d. Any of the above ANS: B

Clavulanic acid is an inhibitor of penicillinase (-lactamase), an enzyme produced by bacteria that can inactivate -lactam-containing enzymes. Clavulanic acid is not effective in circumventing resistance mechanisms.

DIF: Application OBJ: 4

REF: Penicillin Varieties (Specific Penicillins [Ampicillins]) | p. 75 TOP: NBDHE, 6.0. Pharmacology

32. Which of the following statements is true of the cephalosporins? a. They are active against gram-positive but not gram-negative organisms. b. Those available for oral use are susceptible to penicillinase. c. They are bacteriostatic. d. Their mechanism of action is inhibition of cell wall synthesis.

ANS: D

The mechanism of action of the cephalosporins is like that of the penicillins: inhibition of cell wall synthesis. Cephalosporins are active against a wide variety of both gram-positive and gram-negative organisms. Those available for oral use are relatively acid stable and highly resistant to penicillinase.

The cephalosporins, which are bactericidal, are active against most gram-positive cocci, penicillinaseproducing staphylococci, and some gram-negative bacteria.

DIF: Comprehension REF: Cephalosporins (Mechanism of Action) | p. 75 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 33. Large doses of cephalosporins often produce a Coombs reaction, which means a. high blood pressure is exacerbated. b. the immune mechanism is attacking the patient’s own red blood cells. c. degeneration of neural glial cells occurs. d. nephritis of the kidneys occurs.

ANS: B

The Coombs reaction means the immune mechanism is attacking the patient’s own red blood cells, which can lead to a significant degree of hemolysis. The other choices do not properly define a Coombs reaction.

DIF: Recall OBJ: 4

REF: Cephalosporins (Adverse Reactions [Allergy]) | p. 76 TOP: NBDHE, 6.0. Pharmacology

34. A cephalosporin would be most closely related to which of the following agents? a. Penicillin VK b. Clarithromycin c. Ciprofloxacin d. Doxycycline e. Clindamycin ANS: A

Cephalosporins and penicillins have similarities in structure; they are both -lactam antibiotics. They also have the same mechanism of action. Clarithromycin is a macrolide, ciprofloxacin is a fluoroquinolone, doxycycline is a tetracycline, and clindamycin is an analogue of lincomycin, not structurally related to any others. Its mechanism of action is similar to that of macrolides.

DIF: Comprehension REF: Cephalosporins | p. 75 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 35. Which of these agents do not inhibit bacterial cell-wall synthesis? a. Vancomycin b. Erythromycin c. Penicillin G d. Cefazolin ANS: B

Erythromycin is a bacteriostatic agent that inhibits bacterial protein synthesis. Vancomycin, penicillin G, and cefazolin all inhibit cell-wall synthesis. They are bactericidal.

DIF: Recall OBJ: 4

REF: Macrolides (Erythromycin [Mechanism and Spectrum]) | p. 76 TOP: NBDHE, 6.0. Pharmacology

36. Which of the following statements is true concerning the pharmacokinetics of erythromycin? a. Erythromycin is broken down in gastric fluid and absorbed through the stomach

wall. b. Erythromycin is not available in a topical preparation because of allergenicity. c. Erythromycin is available in oral but not injectable forms. d. Erythromycin should be administered 2 hours before or 2 hours after meals.

ANS: D

Erythromycin should be administered 2 hours before or 2 hours after meals. Although food reduces the absorption of erythromycin, administering it with food may be necessary to minimize its adverse gastrointestinal effects. Because erythromycin is broken down in gastric fluid, it is formulated as an enteric-coated tablet, capsule, or insoluble ester to reduce degradation by stomach acid. Erythromycin is administered orally as tablets and capsules, oral suspensions in intravenous and intramuscular forms, and in topical preparations.

DIF: Comprehension REF: Macrolides (Erythromycin [Pharmacokinetics]) | p. 76 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

37. Which of the following conditions is the most common adverse reaction from the administration of

erythromycin? a. Anaphylaxis b. Skin rash c. Gastrointestinal effects d. Miosis ANS: C

The side effects most often associated with erythromycin administration are gastrointestinal and include stomatitis, abdominal cramps, nausea, vomiting, and diarrhea. In one study, at least one gastrointestinal side effect occurred in an average of approximately 50% of patients, with approximately 20% discontinuing their medication because of side effects. The other choices do not represent the most common adverse reaction for the administration of erythromycin.

DIF: Comprehension REF: Macrolides (Erythromycin [Adverse Reactions]) | p. 76 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

38. Which of the following agents is the drug of first choice against infections caused by aerobic

microorganisms in penicillin-allergic patients? a. Metronidazole b. Erythromycin c. Doxycycline d. Clindamycin ANS: B

Because erythromycin is active against essentially the same aerobic microorganisms as penicillin, it is the drug of first choice against these infections in penicillin-allergic patients. Erythromycin is not effective against the anaerobic Bacteroides species implicated in many dental infections. The other choices are not the drug of first choice against aerobic infections in penicillin-allergic patients.

DIF: Comprehension REF: Macrolides (Erythromycin [Uses]) | p. 76 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 39. Azithromycin and clarithromycin a. cause lysis of the bacterial cell wall. b. are not effective against anaerobes. c. have a higher incidence of adverse reactions than erythromycin. d. may be used as alternative antibiotics for the prophylaxis of endocarditis and

prosthetic joint infections.

ANS: D

These macrolides can be used as alternative antibiotics when amoxicillin and clindamycin cannot be used for the prophylaxis of endocarditis and prosthetic joint infections. Azithromycin and clarithromycin inhibit RNA-dependent protein synthesis by binding to the 50S ribosomal subunit. In contrast to erythromycin, azithromycin and clarithromycin have variable action against some anaerobes. The incidence of adverse reactions is lower with azithromycin and clarithromycin compared with erythromycin.

DIF: Comprehension REF: Macrolides (Azithromycin and Clarithromycin) | p. 77 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

40. Which of the following statements is true of the tetracyclines? a. They are bactericidal. b. Tetracyclines interfere with the synthesis of bacterial protein by binding at the 50S

subunit of bacterial ribosomes.

c. In the study of sensitivity or organisms isolated from dental infections, one-fifth to

two-fifths of Staphylococcus aureus (S. aureus) were found to be resistant to tetracycline. d. Tetracyclines are not prone to enterohepatic circulation.

ANS: C

In the study of sensitivity or organisms isolated from dental infections, one-fifth to two-fifths of S. aureus and one-fifth to three-fifths of Streptococcus viridans were found to be resistant to tetracycline.

The tetracyclines are bacteriostatic and interfere with the synthesis of bacterial proteins by binding at the 30S subunit of bacterial ribosomes. Enterohepatic circulation prolongs the action of the tetracyclines after they have been discontinued.

DIF: Comprehension REF: Tetracyclines (Spectrum) | p. 77 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 41. Tetracyclines should not be used in children younger than a. 6 b. 9 c. 12 d. 15

years of age.

ANS: B

If tetracycline is administered between 2 months and 7 or 8 years of age, the permanent teeth will be affected. The mechanism involves the deposition of tetracycline in the enamel of the forming teeth.

These stains are permanent and darken with age and exposure to light. They begin as a yellow fluorescence and progress with time to brown. The other choices do not represent the correct minimum age for administration of tetracyclines. Adult teeth start to form about 6 years prior to eruption and the concern has to do with staining of adult teeth.

DIF: Recall OBJ: 4 42. a. b. c. d.

REF: Tetracyclines (Adverse Reactions [Effects on Teeth and Bones]) | p. 78 TOP: NBDHE, 6.0. Pharmacology

can cause black pigmentation of mandibular and maxillary alveolar bone and the hard palate.

Penicillin V Erythromycin Minocycline Clindamycin

ANS: C

With discontinuation of minocycline, the pigmentation becomes less intense but is usually not completely reversible. When viewed through the mucosa, the pigment appears bluish. Other cases of oral pigmentation have been said to involve the crowns of the permanent teeth and the gingival mucosa. The incidence of this oral pigmentation in adults is 10% after 1 year and 20% after 4 years of therapy. The other choices are not antibiotics that are associated with black pigmentation of mandibular and maxillary alveolar bone and the hard palate.

DIF: Recall OBJ: 4

REF: Tetracyclines (Adverse Reactions [Effects on Teeth and Bones]) | p. 78 TOP: NBDHE, 6.0. Pharmacology

43. Which of the following antibiotics is associated with photosensitivity?

a. b. c. d.

Erythromycin Tetracycline Metronidazole Aminoglycosides (e.g., streptomycin)

ANS: B

Patients taking tetracyclines who are exposed to sunlight sometimes react with exaggerated sunburn.

Patients should be told to use a sunscreen before exposure to the sun. The other antibiotics are not associated with photosensitivity.

DIF: Recall OBJ: 4

REF: Tetracyclines (Adverse Reactions [Photosensitivity]) | p. 78 TOP: NBDHE, 6.0. Pharmacology

44. Which of the following statements is true concerning clindamycin? a. Clindamycin is distributed throughout most body tissues, including bone. b. Cross-resistance between clindamycin and erythromycin is often noted. c. The indications for treatment with clindamycin are limited to a number of

infections caused by aerobic organisms. d. Both A and B are true. e. Both B and C are true.

ANS: D

Clindamycin is distributed throughout most body tissues, including bone but not to cerebrospinal fluid.

Cross-resistance between clindamycin and erythromycin is often noted. An antagonistic relationship has been observed between clindamycin and erythromycin because of competition for the same binding site (50S subunit) on the bacteria. The antibacterial spectrum of clindamycin includes many gram-positive organisms and some gram-negative organisms. Similar to erythromycin, clindamycin’s activity includes S. pyogenes and S. viridans, pneumococci, and S. aureus. In contrast to erythromycin, clindamycin is very active against several anaerobes, including Bacteroides fragilis and Bacteroides melaninogenicus, Fusobacterium species, Peptostreptococcus and Peptococcus species, and Actinomyces israelii.

DIF: Comprehension REF: Clindamycin (Pharmacokinetics) | p. 79 | Clindamycin (Spectrum) | p. 79 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 45. Which of the following agents is most closely associated with the development of pseudomembranous

colitis as a toxicity that limits its general use? a. Erythromycin b. Clindamycin c. Penicillin VK d. Metronidazole ANS: B

A historical association exists between clindamycin use and pseudomembranous colitis, which limits its use relative to other eligible antibacterial agents. Pseudomembranous colitis is a possible consequence related to the use of other antibacterials in addition to the antibiotic most closely associated. Other antibiotics include tetracycline, ampicillin, and the cephalosporins.

DIF: Recall

REF: Clindamycin (Adverse Reactions [Gastrointestinal Effects]) | p. 79

OBJ: 5

TOP: NBDHE, 6.0. Pharmacology

46. Which of the following is the most common adverse reaction to administration of metronidazole? a. Central nervous system effects b. Gastrointestinal effects c. Renal toxicity d. Oral effects ANS: B

Metronidazole’s most common adverse reactions involve the gastrointestinal tract. This side effect occurs in 12% of patients taking metronidazole. It includes nausea, anorexia, diarrhea, and vomiting.

Epigastric distress and abdominal cramping have also been reported. The other choices do not represent the most common adverse reaction to the administration of metronidazole.

DIF: Comprehension REF: Metronidazole (Adverse Reactions [Gastrointestinal Effects]) | p. 80 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 47. Administration of metronidazole for dental infections during pregnancy is a. contraindicated. b. permitted only during the second trimester. c. permitted during the last half of pregnancy. d. permitted without restriction.

ANS: A

Metronidazole is contraindicated during pregnancy. Nursing mothers should not be given metronidazole unless milk is expressed and discarded beginning when the metronidazole is taken and continuing for 48 hours after discontinuing the drug. The other choices are not correct. Metronidazole is in Food and Drug Administration (FDA) pregnancy category B because administration to pregnant mice caused fetal toxicity.

DIF: Recall OBJ: 5 48. a. b. c. d.

REF: Metronidazole (Adverse Reactions [Other Effects]) | p. 80 TOP: NBDHE, 6.0. Pharmacology

is associated with a severe drug interaction with alcohol.

Erythromycin Tetracycline Metronidazole Aminoglycosides (e.g., streptomycin)

ANS: C

Metronidazole is unique among antiinfectives in that it causes a disulfiram-like reaction with alcohol.

Disulfiram is used to treat persons with alcohol problems. Symptoms include nausea, abdominal cramps, flushing, vomiting, or headache. Alcohol should be avoided during administration of metronidazole and for 1 day after therapy has ended. The other antibiotics are not associated with a disulfiram-like reaction.

DIF: Recall OBJ: 5

REF: Metronidazole (Drug Interactions) | p. 80 TOP: NBDHE, 6.0. Pharmacology

49. Which of the following statements is true of vancomycin? a. Vancomycin is related to the cephalosporins. b. Vancomycin is usually administered only intravenously for a systemic effect. c. Vancomycin is bacteriostatic. d. Vancomycin has a broad spectrum of action against a wide variety of gram-

positive and gram-negative organisms.

ANS: B

Because vancomycin has very poor gastrointestinal absorption and causes irritation when used intramuscularly, it is usually administered only intravenously for a systemic effect. Vancomycin is unrelated to any other antibiotic currently marketed. It is bactericidal and has a narrow spectrum of activity against many gram-positive cocci, including both staphylococci and streptococci.

DIF: Comprehension REF: Antimicrobial Agents for Nondental Use (Vancomycin) | p. 81 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 50. An erythematous rash on the face and upper body known as red man syndrome is associated with use

of which of the following antimicrobial agents? a. Augmentin b. Metronidazole c. Vancomycin d. Chloramphenicol ANS: C

Red man syndrome is an adverse reaction noted with intravenous use of vancomycin. Hypotension accompanied by flushing, chills, and drug fever is also associated with vancomycin. The other choices are not associated with red man syndrome.

DIF: Comprehension REF: Antimicrobial Agents for Nondental Use (Vancomycin [Adverse Reactions]) | p. 82 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 51. Aminoglycosides a. are bacteriostatic. b. are used primarily to treat aerobic gram-negative infections when other agents are

ineffective. c. are indicated for stage 1 infections. d. inhibit cell wall synthesis.

ANS: B

Aminoglycosides are used primarily to treat aerobic gram-negative infections when other agents are ineffective. They have little action against gram-positive anaerobic or facultative bacteria. The aminoglycosides are bactericidal. Because they have little action against gram-positive anaerobic or facultative bacteria, aminoglycosides would not be the drug of choice for treatment of a stage 1 infection. Rather, the drug of choice in patients without a penicillin allergy is penicillin V 500 mg every 6 hours for 5 to 7 days. Aminoglycosides appear to inhibit protein synthesis and to act directly on the 30S subunit of the ribosome.

DIF: Comprehension

REF: Antimicrobial Agents for Nondental Use (Aminoglycosides [Spectrum]) | p. 82 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 52. Which of the following antimicrobial agents is associated with ototoxicity? a. Vancomycin b. Aminoglycosides c. Nitrofurantoin d. Quinolones ANS: B

The aminoglycosides are toxic to the eighth cranial nerve, which can lead to auditory and vestibular disturbances, or ototoxicity. Patients may have difficulty maintaining equilibrium and can develop vertigo. Hearing impairment and deafness, which can be permanent, have resulted from the administration of these agents. The side effect is more common in patients with renal failure because the drug accumulates in the body.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Aminoglycosides [Adverse Reactions]) | p. 82 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 53. Oral-cavity infections are generally understood to advance through three stages. The three stages are

(1) mixed aerobic and anaerobic infection, (2) aerobic infection, and (3) anaerobic infection. In what order do these stages occur? a. 1, 2, 3 b. 1, 3, 2 c. 2, 1, 3 d. 3, 1, 2 e. 3, 2, 1 ANS: C

The organisms responsible for a dental infection are primarily aerobic gram-positive cocci, such as Streptococcus viridans. After a short time, the gram-positive infection begins to include a variety of both gram-positive and gram-negative anaerobic organisms, such as Peptostreptococcus (Peptococcus) and Bacteroides (Porphyromonas and Prevotella species). At this point the infection is termed a mixed infection. Over time, the proportion of organisms that are anaerobic increases. The other choices do not correctly depict the sequence of development of an oral cavity infection.

DIF: Application REF: Rational Use of Antiinfective Agents in Dentistry (Stages of Infection) | p. 81 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 54. Which of the following antibiotics would be the best choice for treatment of an acute abscess or

cellulitis in a patient who is not allergic to penicillin? a. Metronidazole b. Erythromycin c. Amoxicillin d. Clindamycin ANS: C

Acute abscess and cellulitis are primarily the result of gram-positive organisms. The drug of choice in patients without a penicillin allergy is penicillin or amoxicillin. The patient must complete the full course of therapy in order to ensure that all of the bacteria are killed off and to help reduce the chance for resistance. The other choices do not represent the first drug of choice.

DIF: Recall REF: Rational Use of Antiinfective Agents in Dentistry (Stages of Infection [Stage 1]) | p. 81 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 55. When a patient with a stage 1 infection is allergic to penicillin V, the best alternative would be a. penicillin G or ampicillin. b. erythromycin ethylsuccinate or clindamycin. c. tetracycline or metronidazole. d. vancomycin.

ANS: B

For a patient with a stage 1 infection who is allergic to penicillin, erythromycin ethylsuccinate or clindamycin may be used. The other antibiotics are not the best choice to use for this circumstance.

DIF: Recall REF: Rational Use of Antiinfective Agents in Dentistry (Stages of Infection [Stage 1]) | p. 81 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 56. Which of the following antibiotics would be the best choice to attack the anaerobes in a stage 2

infection? a. Clindamycin or metronidazole b. Ampicillin or amoxicillin c. Amoxicillin or augmentin d. Ciprofloxacin ANS: A

An antiinfective with good anaerobic coverage is needed. The two antibiotics with the most anaerobic coverage are clindamycin and metronidazole. Penicillin V also has anaerobic coverage. The remaining choices do not have a good anaerobic spectrum of action.

DIF: Recall REF: Rational Use of Antiinfective Agents in Dentistry (Stages of Infection [Stage 2]) | p. 81 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 57. The sulfonamides competitively inhibit the bacterial enzyme that incorporates para-aminobenzoic acid

(PABA) into an immediate precursor of a. biotin. b. thiamine. c. folic acid. d. riboflavin.

ANS: C

Because of their structural similarity to PABA, the sulfonamides competitively inhibit dihydropteroate synthetase, the bacterial enzyme that incorporates PABA into dihydrofolic acid, an immediate precursor of folic acid. Unlike humans, many bacteria are unable to use preformed folic acid, which is essential for their growth. They must synthesize folic acid from PABA. The other choices are not derived from para-aminobenzoic acid.

DIF: Application REF: Antimicrobial Agents for Nondental Use (Sulfonamides [Mechanism of Action]) | p. 82 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 58. The most common adverse reaction to the sulfonamides is a. liver damage. b. suppressed renal function. c. an allergic skin reaction. d. blood dyscrasias.

ANS: C

The most common adverse reaction to the sulfonamides is an allergic skin reaction. These reactions may manifest as rash, urticaria, pruritus, fever, a fatal exfoliative dermatitis, or periarteritis nodosa.

Liver damage, depressed renal function, blood dyscrasias, and precipitation of lupus erythematosus are seen less often.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Sulfonamides [Adverse Reactions]) | pp. 82-83 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 59. Which of the following agents is bacteriostatic in action? a. Amoxicillin b. Streptomycin c. Vancomycin d. Trimethoprim ANS: D

Antibacterials can be bacteriostatic or bactericidal. Trimethoprim is bacteriostatic—it inhibits the growth of bacteria. Amoxicillin, streptomycin, and vancomycin are all bactericidal agents. They kill bacteria.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Sulfamethoxazole-Trimethoprim) | p. 83 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 60. Which of the following statements is true regarding nitrofurantoin? a. Nitrofurantoin has a narrow spectrum of action against anaerobic bacteria. b. Nitrofurantoin is bactericidal. c. Nitrofurantoin is associated with red man syndrome. d. Nitrofurantoin can cause a brownish discoloration of urine.

ANS: D

The most common adverse reactions are nausea, vomiting, and diarrhea, but taking the drug with food decreases these effects. Nitrofurantoin can cause a brownish discoloration of urine. Nitrofurantoin possesses a wide antibacterial spectrum including both gram-positive and gram-negative bacteria. It is bacteriostatic against many common urinary tract pathogens, including Escherichia coli. Vancomycin is associated with red man syndrome.

DIF: Comprehension REF: Antimicrobial Agents for Nondental Use (Nitrofurantoin) | p. 83 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 61. a. b. c. d.

are the first orally active agents against certain Pseudomonas species.

Aminoglycosides Sulfonamides Quinolones Tetracyclines

ANS: C

Quinolones are the first orally active agents against certain Pseudomonas species. They are bactericidal against most gram-negative organisms and many gram-positive organisms. The other choices do not represent the first orally active agent against certain species of Pseudomonas.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Quinolones (Fluoroquinolones)) | p. 83 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 62. Quinolones a. must be administered parenterally and cannot be taken orally. b. have no use in dentistry. c. are bactericidal against most gram-negative organisms and many gram-positive

organisms. d. have cross-resistance with many other antimicrobial agents.

ANS: C

Quinolones are bactericidal against most gram-negative organisms and many gram-positive organisms.

The quinolones are orally effective. This group may have potential use in dentistry because of their spectrum of action. No cross-resistance occurs with other antimicrobial agents.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Quinolones (Fluoroquinolones)) | p. 83 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 63. Which agent inhibits DNA gyrase? a. Penicillin G b. Erythromycin c. Metronidazole d. Ciprofloxacin ANS: D

Ciprofloxacin. The mechanism of action of the quinolones is unique and involves antagonism of the A subunit of DNA gyrase; the enzyme is involved in DNA synthesis. Penicillin G inhibits cell wall synthesis, erythromycin inhibits protein synthesis, and metronidazole disrupts DNA’s helical structure independent of DNA gyrase.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Quinolones (Fluoroquinolones)) | p. 83 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 64. Unlike other antiinfective agents, an additive action may result when

_ is combined with other

antimicrobial agents. a. vancomycin b. chloramphenicol c. nitrofurantoin d. ciprofloxacin ANS: D

An additive action may result when ciprofloxacin is combined with other antimicrobial agents. The emergence of organisms resistant to the fluoroquinolones and the cross-resistance among the fluoroquinolones is increasing. Use of fluoroquinolones in chickens may be partially responsible for increasing resistance. The other choices do not have an additive action when combined with other antimicrobial agents.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Quinolones (Fluoroquinolones) [Spectrum]) | p. 83 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 65. The drug whose future use may include organisms found in periodontal disease is a. ofloxacin. b. sulfamethoxazole. c. macrodantin. d. streptomycin.

ANS: A

Ofloxacin’s spectrum of action most closely parallels the spectrum of microbes found in dental infections. Sulfa drugs have no use in dentistry. Macrodantin is used for urinary tract infections (UTIs). Streptomycin was formerly used prophylactically for heart valve replacement; however, orally active agents are now recommended.

DIF: Application REF: Antimicrobial Agents for Nondental Use (Quinolones (Fluoroquinolones)) | p. 84 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 66. Rupture of the Achilles tendon is associated with the use of a. tetracyclines. b. quinolones. c. rifampin. d. mupirocin.

ANS: B

An unusual reaction affecting the Achilles tendon has become fairly common in patients taking quinolones. These agents can produce tendonitis or tendon rupture in the Achilles tendon. In 2008, the FDA issued a boxed warning alerting patients to the serious risk of tendon damage and rupture. In 2013, the FDA strengthened its warning regarding the risk of sudden, serious, and potentially permanent peripheral neuropathy. In 2016, the FDA enhanced warnings regarding the association of quinolones for permanent side effects associated with tendons, muscles, joints, nerves and the central nervous system. These choices are not associated with rupture of the Achilles tendon.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Quinolones (Fluoroquinolones [Warnings]) | pp. 83-84 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 67. Which of the following combinations of three drugs are administered concurrently in active cases of

pulmonary tuberculosis (TB)? a. Pyrazinamide (PZA), rifapentine, and Rifater b. Isoniazid (INH), rifampin, and pyrazinamide c. Ethambutol, isoniazid (INH), and Rifater d. Rifampin, PZA, and streptomycin ANS: B

INH, rifampin, and PZA are combined for the treatment of pulmonary TB. INH and rifampin are continued every day for 9 to 12 months. PZA is continued for 2 months. With susceptible organisms, a patient, if compliant, usually becomes noninfective within 2 to 3 weeks. These choices do not represent the combination of three drugs that are administered in active cases of tuberculosis.

DIF: Recall REF: Antituberculosis Agents | p. 84 TOP: NBDHE, 6.0. Pharmacology

OBJ: 8

68. If a person with active TB seeks oral health care a. use standard precautions and treat him or her just as everyone else is treated. b. schedule him or her as the last patient of the day. c. contact that person’s physician and delay health care until the disease is no longer

in the active state. d. refer the patient to a hospital with a dental suite for treatment.

ANS: C

Contact that person’s physician and delay health care until the disease is no longer in the active state.

This person should be in the dental office only for evaluation of his or her dental condition and in order to make a referral. These choices do not represent Centers for Disease Control (CDC) recommendations for management of a patient with active tuberculosis.

DIF: Recall REF: Antituberculosis Agents | p. 84 TOP: NBDHE, 6.0. Pharmacology

OBJ: 8

69. Antibiotic prophylaxis to prevent endocarditis is considered reasonable for which of the following

dental procedures? a. Oral radiographs b. Routine anesthetic injections through uninfected tissues c. Routine prophylaxis

d. Shedding of deciduous teeth ANS: C

Antibiotic prophylaxis is considered reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth or perforation of the oral mucosa. Antibiotic prophylaxis is not necessary for routine anesthetic injections through uninfected tissues, oral radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa.

DIF: Application REF: Antibiotic Prophylaxis Used in Dentistry (Prevention of Infective Endocarditis [Dental Procedures] [Box 7.5: Dental Procedures for Which Endocarditis Prophylaxis is Reasonable for Patients with Specific Cardiac Conditions]) | p. 86 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 70. Infective endocarditis prophylaxis with an antiinfective is indicated for patients who have had a. coronary artery bypass surgery. b. a prosthetic heart valve. c. functional murmur. d. a cardiac pacemaker.

ANS: B

Patients with prosthetic heart valves constitute a population at risk for developing infective endocarditis. Coronary artery bypass surgery, functional murmur, and cardiac pacemaker are all conditions that most clinicians believe do not require prophylactic antibiotic coverage.

DIF: Comprehension REF: Antibiotic Prophylaxis Used in Dentistry (Prevention of Infective Endocarditis [Cardiac Conditions]) | p.

86 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 71. The standard antibiotic drug regimen prior to dental procedures requiring immunoprophylaxis in a

patient with no allergies to penicillin or amoxicillin is procedure. a. 1; 1 b. 1; 2 c. 2; 1 d. 2; 2

g of amoxicillin

hour(s) before the

ANS: C

For a patient with no allergies to penicillin or amoxicillin, the standard prophylactic drug regimen is 2 g of amoxicillin 1 hour before the procedure. These choices do not represent the American Heart Association regimen to prevent endocarditis subsequent to a dental procedure.

DIF: Recall REF: Antibiotic Prophylaxis Used in Dentistry (Prevention of Infective Endocarditis [Dental Procedures] [Table 7.7: Prophylactic Antibiotic Drug Regimens for Dental Procedures]) | p. 87 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology

72. If a patient requires premedication with antibiotics before a dental procedure and he or she is allergic

to penicillins or ampicillin but can take oral medication, the drug of choice is a. tetracycline. b. metronidazole. c. cephalexin. d. amoxicillin.

ANS: C

The drug of choice is 2 g of cephalexin. Alternatively, 600 mg of clindamycin, or 500 mg of azithromycin, or 500 mg of clarithromycin may be prescribed. Tetracycline and metronidazole are not recommended antibiotics for immunoprophylaxis prior to a dental procedure in order to prevent endocarditis. Amoxicillin is contraindicated because it is a relative of ampicillin.

DIF: Comprehension REF: Antibiotic Prophylaxis Used in Dentistry (Prevention of Infective Endocarditis [Dental Procedures] [Table 7.7: Prophylactic Antibiotic Drug Regimens for Dental Procedures]) | p. 87 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 73. Both the American Dental Association (ADA) and the American Academy of Orthopedic Surgeons

(AAOS) recommend that which type of patients with joint replacements should receive antibiotic prophylaxis before dental procedures that can lead to bacteremia? a. All patients for the rest of their lives b. All patients for 2 years c. Patients with weakened immune systems d. No patients ANS: C

Patients with joint replacement with a weakened immune system should speak with their dentist or orthopedist about the necessity for antibiotics. Both the ADA and AAOS recommend not routinely prescribing antibiotic prophylaxis in patients with joint replacements, but there are some patients for whom consultation with their practitioner is advised.

DIF: Comprehension REF: Antibiotic Prophylaxis Used in Dentistry (Prosthetic Joint Prophylaxis) | p. 88 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 74. Penicillin kills bacteria by attacking the a. 50S subunit of the ribosome. b. 30S subunit of the ribosome. c. cell wall. d. a subunit of DNA gyrase.

ANS: C

Penicillin attaches to penicillin-binding proteins on the bacterial cell membrane. Penicillin inhibits the formation of cross-linkages and destroys cell wall integrity leading to lysis. Erythromycin works by inhibiting peptidyl transferase at the 50S ribosomal subunit. Tetracyclines interfere with the synthesis of bacterial protein by binding at the 30S subunit of bacterial ribosomes. Quinolones interfere with the enzyme DNA gyrase.

DIF: Comprehension

REF: Penicillin Varieties (Mechanism of Action) | p. 73

OBJ: 1

TOP: NBDHE, 6.0. Pharmacology

75. Which antibiotic is useful in the treatment of many anaerobic periodontal infections? a. Metronidazole b. Penicillin VK c. Erythromycin d. Azithromycin ANS: A

Metronidazole, due to its anaerobic efficacy. Metronidazole has antiinflammatory effects in addition to antiinfective effects. It affects neutrophil motility, lymphocyte action, and cell-mediated immunity.

Penicillin or amoxicillin are good choices for an acute abscess. Erythromycin or azithromycin may be used if the patient is allergic to penicillin.

DIF: Comprehension REF: Metronidazole (Uses [Dental]) | p. 81 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 76. The American Dental Association (ADA) and the American Academy of Orthopedic Surgeons

(AAOS) recommend for dentists to prescribe antibiotic prophylaxis for patients with joint replacements. The American Dental Association Council on Scientific Affairs demonstrated the benefits of antibiotic prophylaxis outweigh potential harm. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false. d. The first statement is false, the second statement is true.

ANS: B

The most recent recommendations recommend that dentists limit antibiotic prophylaxis in patients with joint replacement. The ADA Council on Scientific Affairs showed the benefits of antibiotic prophylaxis do not outweigh the potential for harm in most patients. Both the ADA and AAOS do not recommend routinely prescribing antibiotic prophylaxis for patients with joint replacements.

DIF: Comprehension REF: Antibiotic Prophylaxis Used in Dentistry (Prosthetic Joint Prophylaxis) | p. 88 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 77. Infective endocarditis is more likely to occur from bacteria entering the bloodstream as a result of daily

activities than from a dental procedure. There is no evidence that antibiotic prophylaxis prior to a dental procedure will prevent infective endocarditis in those at risk for developing it. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false. d. The first statement is false, the second statement is true.

ANS: A

This information has led to a change in the guidelines and far fewer antibiotics are being prescribed to patients as a result. Daily activities are more likely to lead to infective endocarditis than a dental procedure. A comprehensive review of published studies found there was no compelling evidence in the medical and dental literature that antibiotic prophylaxis before a dental procedure would prevent infective endocarditis in those at risk for developing it.

DIF: Comprehension REF: Antibiotic Prophylaxis Used in Dentistry (Prevention of Infective Endocarditis) | p. 86 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 78. An allergic reaction to penicillin will most likely appear as a. anaphylaxis. b. a rash. c. delayed serum sickness. d. hemolytic anemia. e. interstitial nephritis.

ANS: B

A rash accounts for 80% to 90% of allergic reactions to penicillin. It is estimated that anaphylactic reactions occur in up to 0.05% of penicillin-treated patients. Serum sickness usually takes at least 6 days to develop. Interstitial nephritis, hemolytic anemia, and eosinophilia are occasionally reported following administration of penicillin.

DIF: Comprehension REF: Penicillin Varieties (Adverse Reactions [Allergy and Hypersensitivity]) | p. 74 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 79. Which type of penicillin is most likely to be administered to a patient in the dental office? a. Penicillin G b. Penicillin V c. Penicillinase-resistant penicillin d. Ampicillin e. Ticarcillin ANS: B

The potassium salt of penicillin V is more soluble than the free acid and better absorbed when taken orally. Penicillin G is thought of as an injectable penicillin. The remaining penicillins are more costly and have more side effects than penicillin V. DIF: Application OBJ: 4

REF: Penicillin Varieties (Specific Penicillins [Penicillin V]) | p. 74 TOP: NBDHE, 6.0. Pharmacology

80. Which is a penicillinase-resistant penicillin? a. Ampicillin b. Amoxicillin c. Cloxacillin d. Ticarcillin e. Piperacillin ANS: C

Cloxacillin and dicloxacillin are both penicillinase-resistant penicillins. Ampicillin and amoxicillin are both penicillinase-susceptible penicillins. Ticarcillin and piperacillin are extended-spectrum penicillins that are not penicillinase resistant.

DIF: Recall

REF: Penicillin Varieties (Specific Penicillins [Penicillinase-Resistant Penicillins]) | p. 74 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 81. The frequency of cross-hypersensitivity between penicillin and cephalosporins is about a. 0 b. 10 c. 20 d. 30 e. 40

%.

ANS: B

The frequency is about 10%. The incidence is higher in patients with a history of penicillin allergy.

Zero percent is not correct. Some cross-hypersensitivity can occur because the cephalosporins and penicillin have similar structures; however, it is 10%.

DIF: Recall OBJ: 4

REF: Cephalosporins (Adverse Reactions [Allergy]) | p. 76 TOP: NBDHE, 6.0. Pharmacology

82. Which is a macrolide antibiotic? a. Azithromycin b. Cefixime c. Doxycycline d. Ciprofloxacin e. Neomycin ANS: A

The macrolide antibiotics include erythromycin, clarithromycin, and azithromycin. Cefixime is a second-generation cephalosporin. Doxycycline is a form of tetracycline. Ciprofloxacin is a quinolone.

Neomycin is an aminoglycoside.

DIF: Recall OBJ: 4

REF: Macrolides (Azithromycin and Clarithromycin) | p. 77 TOP: NBDHE, 6.0. Pharmacology

83. Tetracycline antibiotics are associated with development of a. medication related osteonecrosis of the jaw (MRONJ) b. bone resorption c. osteogenic sarcoma d. Kaposi sarcoma e. candidiasis

in patients with dentures?

ANS: E

Patients with dentures are at a higher risk for candidiasis caused by a superinfection. MRONJ is associated with the use of bisphosphonates to prevent osteoporosis. Bone resorption is a natural process following tooth removal. Tetracycline antibiotics are not related to an increased incidence of sarcomas.

DIF: Comprehension REF: Tetracyclines (Adverse Reactions [Gastrointestinal Effects]) | p. 78 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology

84. Which antibiotic is utilized particularly due to effectiveness against anaerobic bacteria? a. Penicillin b. Erythromycin c. Metronidazole d. Clindamycin e. Tetracycline ANS: C

Metronidazole has special usefulness due to its anaerobic spectrum. It has exceptional action against most obligate anaerobes. Penicillin, erythromycin, clindamycin, and tetracycline are not known as first choice antibiotics against anaerobic bacteria.

DIF: Comprehension REF: Metronidazole (Uses) | p. 81 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Which of the following statements are true concerning antibiotic-resistant infections? (Select all that

apply.) a. More than 10% of patients with antibiotic-resistant infections in the United States each year will die from their infection. b. Natural resistance occurs when an organism that was previously sensitive to an antimicrobial agent develops resistance. c. Microbial organisms have the ability to transfer genetic material from one to another so that an organism may become resistant to an antibiotic without ever having been exposed to the antibiotic. d. The development of new antibiotics has greatly reduced the number of antibioticresistant bacteria over the past 10 years.

ANS: A, C

There are a reported 2 million cases of antibiotic-resistant infections in the United States each year with approximately 230,000 reported deaths from these infections. One organism may transfer DNA to another via transduction, transformation, or bacterial conjugation. The first organism, which is resistant to one or more antibiotics, transfers its genetic material to a second organism. The second organism, which was not previously resistant, thus becomes resistant to the same antibiotic as the first organism without ever having been exposed to that antibiotic. Natural resistance occurs when an organism has always been resistant to an antimicrobial agent because of the bacteria’s normal properties such as lipid structures in the cell wall. The number of antibiotic-resistant bacteria has increased dramatically over the past 10 years, and many bacterial infections are becoming resistant to some of the most commonly prescribed antibiotics.

DIF: Comprehension REF: Resistance | pp. 69-70 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following groups of penicillins are most commonly used in dentistry? (Select all that

apply.) a. Penicillin G and V b. Penicillinase-resistant penicillins c. Amoxicillin

d. Extended-spectrum penicillins ANS: A, C

The penicillins can be divided into four major groups. The first group contains penicillin G and V, the second group is composed of the penicillinase-resistant penicillins, the third group contains amoxicillin, and the fourth group consists of extended-spectrum penicillins. The first and third groups are commonly used in dentistry. Penicillinase-resistant penicillins should be reserved for use against only penicillinase-producing staphylococci. Extended-spectrum penicillins have a wider spectrum of action than penicillin G and are used to treat systemic infections.

DIF: Comprehension REF: Penicillin Varieties | p. 72 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 3. Which of the following are true of a stage 3 infection? (Select all that apply.) a. Most patients will require the use of antibiotics. b. The infection contains both gram-positive and gram-negative organisms. c. Clindamycin and metronidazole are useful antibiotics. d. The organisms have coalesced into one area.

ANS: C, D

The organisms have coalesced into one area in a stage 3 infection. The use of an antibiotic with anaerobic coverage is warranted if a chronic stage 3 infection persists or if the patient is immunocompromised. Clindamycin and metronidazole are the two antibiotics with the most anaerobic coverage. Incision and drainage are most often sufficient for patients with a stage 3 infection. The organisms are almost solely anaerobic.

DIF: Comprehension REF: Evolution of a Dental Infection | p. 69 | Rational Use of Antiinfective Agents in Dentistry (Stages of Infection [Stage 3]) | p. 81 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 4. Which of the following are true about sulfamethoxazole (SMX) and trimethoprim (TMP)? (Select all

that apply.) a. They are bactericidal. b. They act by sequential inhibition of folic acid synthesis. c. They are used to treat urinary tract infections (UTIs). d. They are often used to treat refractory periodontitis.

ANS: B, C

Sulfamethoxazole and trimethoprim are folate synthesis inhibitors. They are commonly used in combination as co-trimoxazole, SMX-TMP, Bactrim, or Septra. This drug is indicated for the treatment of selected urinary tract infections and selected respiratory and gastrointestinal infections. It is used to treat acute otitis media in children. SMX-TMP is bacteriostatic against a wide variety of gram-positive bacteria and some gram-negative bacteria. SMX-TMP has no documented use in dentistry. Pediatric patients coming to the dental office may be taking it to prevent chronic ear infections.

DIF: Recall REF: Antimicrobial Agents for Nondental Use (Sulfamethoxazole-Trimethoprim) | p. 83 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology

5. Prophylactic antibiotics are recommended for which procedure? (Select all that apply.) a. Dental x-ray images b. Routine injections of dental anesthetic c. Dental prophylaxis d. Placement of orthodontic brackets e. Periodontal probing ANS: C, E

Antibiotic prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue. Antibiotics are not recommended for dental x-ray imaging. They are not recommended for injections because both the anesthetic and needle are sterile. They are not recommended prior to placement of orthodontic brackets or for adjustment of orthodontic appliances.

DIF: Application REF: Antibiotic Prophylaxis Used in Dentistry (Prevention of Infective Endocarditis [Dental Procedures] [Box 7.5: Dental Procedures for Which Endocarditis Prophylaxis is Reasonable for Patients with Specific Cardiac Conditions]) | p. 86 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Antiinfectives are not needed in oral cavity infections if drainage of the infected area can be

established.

ANS: T

For most localized dental infections, antiinfective agents are not indicated if adequate drainage can be obtained, unless the patient is immunocompromised.

DIF: Recall REF: Introduction | p. 68 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. Metronidazole has antiinflammatory activity.

ANS: T

Metronidazole has antiinflammatory effects in addition to antiinfective effects. It affects neutrophil motility, lymphocyte action, and cell-mediated immunity.

DIF: Recall REF: Metronidazole | p. 80 TOP: NBDHE, 6.0. Pharmacology

OBJ: 5

Chapter 08: Antifungal and Antiviral Agents Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. The mechanism of action of nystatin involves binding to the a. 30S ribosomal subunit of bacterial rRNA. b. 50S ribosomal subunit of bacterial rRNA. c. sterols in the fungal cell membrane.

d. enzymes in the nucleus of molds.

ANS: C

Binding to sterols in the fungal cell membrane produces an increase in membrane permeability and allows leakage of potassium and other essential cellular constituents. Nystatin is an antifungal rather than antibacterial agent. The mechanism of action of nystatin does not involve the nucleus of molds.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Nystatin) | p. 90 TOP: NBDHE, 6.0. Pharmacology

2. Which of the following agents has poor oral absorption? a. Nystatin b. Itraconazole c. Terbinafine d. Griseofulvin ANS: A

Nystatin is not absorbed from the mucous membranes or through intact skin; taken orally, it is poorly absorbed from the gastrointestinal tract. Itraconazole, terbinafine, and griseofulvin all have good oral bioavailability.

DIF: Comprehension REF: Antifungal Agents (Nystatin) | p. 90 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. Nystatin is used for both the treatment and the prevention of a. blastomycosis b. histoplasmosis c. oral candidiasis d. tinea

in susceptible cases.

ANS: C

Nystatin is used both for the treatment and prevention of oral candidiasis in susceptible cases.

Although Candida albicans is a frequent inhabitant of the oral cavity, it produces disease only under unusual circumstances. Patients affected are often immunocompromised. Nystatin is not absorbed from the mucous membranes or through intact skin. Blastomycosis and histoplasmosis are systemic fungal infections. Ketoconazole (Nizoral) and fluconazole (Diflucan) are systemic drugs that are used to treat systemic fungal infections; however, they also may be used for mucocutaneous candidiasis.

Tinea refers to fungal skin infections such as athlete’s foot.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Nystatin) | p. 90 TOP: NBDHE, 6.0. Pharmacology

4. The main advantage of nystatin pastilles over the aqueous suspension is that a. the pastilles do not contain sugar like the suspension. b. 15 minutes are required for the lozenge to dissolve in the mouth. c. the pastilles have twice rather than four times dosing a day as in the suspension,

improving compliance. d. the pastilles are swallowed, whereas the suspension should be spit out.

ANS: B

It takes 15 minutes for the lozenge to dissolve in the mouth, thus bathing lesions in the antifungal agent for a longer period. Both the suspension and the pastilles contain sugar. The instructions for the aqueous suspension for children and adults are to swish, swirl, expectorate, or swallow 4 to 6 ml four to five times daily. The instructions for the pastilles are to suck on one to two tablets four to five times daily.

DIF: Comprehension REF: Antifungal Agents (Nystatin) | p. 90 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Which of the following statements is true concerning clotrimazole? a. It is available in the form of an aqueous suspension for oral use. b. It is the only antifungal for oral use that does not contain sugar. c. Clotrimazole has been reported to produce elevated liver enzyme levels in

approximately 85% of patients. d. Systemic clotrimazole should not be administered to a pregnant woman.

ANS: D

Clotrimazole is not recommended for pregnant women and children under the age of 3 years.

Clotrimazole is available in the form of a slowly dissolving, sugar-containing lozenge for oral use. It has been reported to produce elevated liver enzyme (aspartate aminotransferase) levels in approximately 15% of patients.

DIF: Comprehension REF: Antifungal Agents (Imidazoles [Clotrimazole]) | p. 91 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

6. The most frequent adverse reaction(s) associated with ketoconazole is (are) a. diarrhea. b. nausea and vomiting. c. xerostomia. d. premature ventricular contractions.

ANS: B

The most frequent adverse reactions associated with ketoconazole are nausea and vomiting. Taking ketoconazole with food can minimize these reactions. The remaining choices are not the most frequent adverse reactions associated with ketoconazole. Other adverse reactions with ketoconazole include drug interactions, hepatocellular dysfunction, and teratogenic potential.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Imidazoles [Ketoconazole]) | p. 91 TOP: NBDHE, 6.0. Pharmacology

7. The most serious adverse reaction associated with ketoconazole is a. tachycardia. b. hepatotoxicity. c. hypotension. d. achlorhydria.

ANS: B

The most serious adverse reaction is hepatotoxicity. Its incidence is at least 1:10,000. It is usually reversible on discontinuation of the drug, but, occasionally, it has been fatal. With extended use, the patient should have periodic liver function tests. The other choices do not represent the most serious adverse reaction with use of ketoconazole. Tachycardia is a rapid heart rate, hypotension is low blood pressure, and achlorhydria is a lack of hydrochloric acid from gastric contents of the stomach.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Imidazoles [Ketoconazole]) | p. 91 TOP: NBDHE, 6.0. Pharmacology

8. Which of the following is not an imidazole? a. Clotrimazole b. Ketoconazole c. Fluconazole d. Nystatin ANS: D

Nystatin is not an imidazole. It is an antifungal agent that is produced by Streptomyces noursei.

Clotrimazole, miconazole, and ketoconazole are imidazoles that are useful in dentistry. Fluconazole is also an imidazole. It is indicated for treatment of oropharyngeal and esophageal candidiasis and serious systemic candidal infections.

DIF: Comprehension REF: Antifungal Agents (Nystatin) | p. 90 | Antifungal Agents (Imidazoles) | p. 90 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 9. The following statements are true of ketoconazole except which one? a. Ketoconazole is an imidazole that is used in dentistry. b. Hepatotoxicity subsequent to the administration of ketoconazole is thought to be

an idiosyncratic reaction. c. Ketoconazole has a masculinizing effect by increasing testosterone levels. d. At least 2 hours should pass between the ingestion of an antacid and the

administration of ketoconazole. e. Ketoconazole is available as a cream.

ANS: C

Ketoconazole inhibits sex steroid biosynthesis, including testosterone, perhaps by blocking several P450 steps. This effect can, in men, produce gynecomastia and impotence. All of the other choices are true. Ketoconazole is an imidazole. Hepatotoxicity subsequent to the administration of ketoconazole is thought to be an idiosyncrasy, which is neither a side effect nor an allergic reaction. At least 2 hours should pass between the administration of any agent that reduces the amount of stomach acid and the use of ketoconazole, and ketoconazole is available as a cream.

DIF: Comprehension REF: Antifungal Agents (Imidazoles [Ketoconazole]) | p. 91 TOP: NBDHE, 6.0. Pharmacology 10. Ketoconazole should not be used with a. penicillin V b. metronidazole c. anticholinergic agents

OBJ: 1

because it could reduce the absorption of ketoconazole.

d. acyclovir ANS: C

Ketoconazole requires an acidic environment for the dissolution and absorption. Agents such as H 2 receptor blockers, H+-pump inhibitors, anticholinergic agents, and antacids that alter the amount of stomach acid could theoretically reduce the absorption of ketoconazole. The other choices are not associated with reduced absorption due to alteration of stomach acid.

DIF: Comprehension REF: Antifungal Agents (Imidazoles [Ketoconazole]) | p. 92 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

11. Thrush is a. an allergic reaction. b. an idiosyncrasy. c. oropharyngeal candidiasis. d. a serious systemic fungal infection.

ANS: C

Thrush is oropharyngeal candidiasis. Thrush is not an allergic reaction nor is it an idiosyncrasy. Thrush is not a serious systemic fungal infection.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Imidazoles [Ketoconazole]) | p. 91 TOP: NBDHE, 6.0. Pharmacology

12. All of the following are antifungal agents that are useful in dentistry except a. miconazole. b. docosanol. c. clotrimazole. d. ketoconazole.

ANS: B

Docosanol is an antiviral used to treat recurrent orolabial herpes. The other choices listed are used in dentistry.

DIF: Recall REF: Antiviral Agents (Herpes Simplex [Docosanol 10%]) | p. 93 | Antifungal Agents (Imidazoles) | p. 90 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 13. Which of the following is used prophylactically against candidiasis in immunocompromised patients

or for the treatment of candidal infections that do not respond to other agents? a. Nystatin b. Ketoconazole c. Fluconazole d. Clotrimazole ANS: C

Fluconazole is indicated for prophylaxis against candidiasis in immunocompromised patients and for the treatment of oropharyngeal and esophageal candidiasis and serious systemic candidal infections.

The remaining choices are not antifungal medications that are used prophylactically to prevent candidiasis in immunocompromised patients.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Imidazoles [Other Imidazoles]) | p. 92 TOP: NBDHE, 6.0. Pharmacology

14. Which of the following is the usual adult dose of ketoconazole for the treatment of Candida species? a. 5 ml of aqueous suspension (100,000 U/ml) four times daily b. 200 to 400 mg orally daily c. One pastille four to five times daily d. One troche one to five times daily ANS: B

Ketoconazole is available as a tablet or cream. The usual adult dose of ketoconazole for the treatment of Candida species is 200 to 400 mg orally (PO) daily (qid). Nystatin is administered as 5 ml of aqueous suspension (100,000 U/ml) four times daily or as a pastille. Clotrimazole is administered as a troche.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Imidazoles [Ketoconazole]) | p. 92 TOP: NBDHE, 6.0. Pharmacology

15. Which of the following antifungal agents is produced by Streptomyces noursei? a. Fluconazole b. Clotrimazole c. Ketoconazole d. Nystatin ANS: D

Nystatin is a prescription antifungal agent that is produced by Streptomyces noursei. The remaining antifungal agents are not produced by Streptomyces noursei.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Nystatin) | p. 90 TOP: NBDHE, 6.0. Pharmacology

16. Which of the following is a synthetic antifungal agent available in the form of a slowly dissolving,

sugar-containing lozenge for oral use? a. Clotrimazole b. Ketoconazole c. Fluconazole d. Nystatin ANS: A

Clotrimazole is available as a lozenge (troche) for oral use and also as a cream for topical application.

The other choices are not available as a lozenge (troche) although nystatin is available as a pastille.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Imidazoles [Clotrimazole]) | p. 90 TOP: NBDHE, 6.0. Pharmacology

17. Viruses are difficult to treat because they cooperate with the host’s cells. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false.

d. The first statement is false, the second is true.

ANS: A

The search for drugs useful in the treatment of viral infections has posed the greatest problem of all infectious organisms, which is because viruses are obligate intracellular organisms that require cooperation from their host’s cells. Therefore, to kill the virus, often the host’s cell must also be harmed. Both parts of the statement are true.

DIF: Application REF: Antiviral Agents | p. 92 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

18. Which of the following is true of acyclovir? a. It works by inhibiting replication of deoxyribonucleic acid (DNA). b. It should be taken on an empty stomach because food affects the drug’s absorption. c. The antiviral action of acyclovir includes herpes simplex viruses types 1 and 2

(HSV-1 and HSV-2), but it is not effective against varicella-zoster virus or Epstein-Barr virus. d. The most common adverse effects associated with oral acyclovir are anorexia and a funny taste in the mouth.

ANS: A

Acyclovir works by inhibiting replication of DNA. Food does not affect the drug’s absorption. The antiviral action of acyclovir includes various herpesviruses, including HSV-1 and HSV-2, varicellazoster, Epstein-Barr, Herpesvirus simiae (B virus), and cytomegalovirus. One of the most common adverse effects associated with oral acyclovir is headache (13%). Anorexia and a funny taste in the mouth have been reported rarely.

DIF: Comprehension REF: Antiviral Agents (Herpes Simplex [Acyclovir]) | p. 92 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

19. Topical acyclovir a. will prevent the transmission of herpes labialis. b. has been effective in the treatment of herpes labialis infections in

nonimmunocompromised patients. c. does not prevent the recurrence of herpes labialis. d. Both A and B are correct. e. Both B and C are correct.

ANS: C

Topical acyclovir does not prevent the recurrence of herpes labialis. Topical acyclovir will not prevent the transmission of herpes labialis. It has not been effective in the treatment of recurrent herpes genitalis or herpes labialis infections in nonimmunocompromised patients. It does produce a limited shortening in the duration of viral shedding in male patients by a few hours.

DIF: Comprehension REF: Antiviral Agents (Herpes Simplex [Acyclovir]) | p. 92 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

20. Which dose form of acyclovir has been effective for the treatment of herpes labialis in an

immunocompromised person? a. Oral b. Topical c. Pastille d. Troche ANS: A

A dose of 400 mg five times daily for 10 days has been shown to be effective and is often used to treat HSV-1. Topical acyclovir has not been effective in the treatment of herpes labialis infections in nonimmunocompromised infections. Although available literature does not support the use of topical acyclovir for management of herpes labialis in dentistry, it is used extensively. Acyclovir is not available in pastilles or troches.

DIF: Comprehension REF: Antiviral Agents (Herpes Simplex [Acyclovir]) | p. 93 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

21. Docosanol 10% has been shown to decrease healing time by about

in patients with recurrent orolabial herpes when started within 12 hours of the appearance of prodromal symptoms. a. one half day b. 2 days c. 5 days d. 7 to 10 days ANS: A

Docosanol 10% has been shown to decrease healing time by about one half day in patients with recurrent orolabial herpes when started within 12 hours of the appearance of prodromal symptoms.

The remaining choices do not correctly represent the decrease in healing time for patients taking Docosanol 10%.

DIF: Recall OBJ: 2

REF: Antiviral Agents (Herpes Simplex [Docosanol 10%]) | p. 93 TOP: NBDHE, 6.0. Pharmacology

22. A patient reports a sudden onset of illness with a fever of 102 Fahrenheit, chills, a dry cough, body

aches, and a sore throat. They deny the loss of sense of taste or smell. The symptoms indicate it most likely is a. environmental allergies. b. seasonal influenza or COVID-19. c. wheat gluten allergy. d. the common cold.

ANS: B

It most likely is flu or COVID-19. Because COVID-19 can present with a wide range of symptoms an antibody test could differentiate whether or not it is seasonal flu or COVID-19. The high fever could indicate either seasonal influenza or COVID-19. Chills are commonly seen with seasonal influenza, however, chills may occur sometimes in cases of COVID-19. A dry cough is common with both flu and COVID-19. Body aches and a sore throat are common with flu and sometimes are seen with COVID-19. Cold symptoms are gradual in onset, while flu symptoms are sudden.

DIF: Application REF: Antiviral Agents (Influenza [Table 8.4: Allergies Versus Cold Versus Flu Versus COVID-19 Symptoms]) | pp. 93-94 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 23. Which is a polymerase acidic (PA) endonuclease inhibitor indicated for treatment of acute,

uncomplicated symptoms of influenza in persons older than 12 years of age? a. Oseltamivir phosphate (Tamiflu) b. Zanamivir (Relenza) c. Baloxavir marboxil (Xofluza) d. Molnupiravir ANS: C

Baloxavir marboxil is also approved to treat those 12 years and older for postexposure prophylaxis of influenza. Baloxavir marboxil is unique in that it is a one-time dose of 80 mg for those weighing 80 kg and 40 mg for those weighing <80 kg. Limitations for using baloxavir marboxil include such factors as the virus type or subtype, resistance, and changes in viral virulence which could all negatively affect the efficacy of the drug. Adverse effects include diarrhea, nausea, bronchitis, sinusitis, and headache.

DIF: Recall OBJ: 2 24. a. b. c. d.

REF: Antiviral Agents (Influenza [Baloxavir marboxil]) | p. 93 TOP: NBDHE, 6.0. Pharmacology

is a monoclonal antibody drug that may be used to treat COVID-19.

Oseltamivir phosphate (Tamiflu) Casirivimab plus imdevimab (REGEN-COV) Molnupiravir Baloxavir marboxil (Xofluza)

ANS: B

Casirivimab plus imdevimab (REGEN-COV) and bamlanivimab plus etesevimab are investigational monoclonal antibody drugs that have been given FDA Emergency Use Authorization for the treatment of mild-to-moderate COVID-19 in persons who are at high risk for progression to severe disease.

Tamiflu is used for the treatment of acute, uncomplicated influenza. Molnupiravir is a ribonucleoside analog. Baloxavir marboxil (Xofluza) is a polymerase acidic (PA) endonuclease inhibitor.

DIF: Recall OBJ: 2

REF: Antiviral Agents (SARS-CoV-2 virus [Monoclonal antibodies]) | p. 94 TOP: NBDHE, 6.0. Pharmacology

25. Which of the following statements is true of zidovudine (AZT, Retrovir)? a. It prevents cells containing human immunodeficiency virus (HIV) from b. c. d. e.

replicating.

The toxicity of zidovudine is related to bone marrow depression.

It has no effect on the number and frequency of opportunistic infections.

Both A and B are true.

Both B and C are true.

ANS: B

Zidovudine was the first nucleoside reverse transcriptase inhibitor. The toxicity of zidovudine is related to bone marrow depression, which can lead to anemia, granulocytopenia, and thrombocytopenia. Zidovudine has no effect on cells already containing HIV. It inhibits HIV synthesis and reduces the morbidity and mortality from AIDS and AIDS-related complex. Opportunistic infections are reduced in both number and frequency.

DIF: Comprehension REF: Antiviral Agents (Acquired Immunodeficiency Syndrome [Nucleoside/Nucleotide Reverse Transcriptase Inhibitors]) | p. 94 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 26. Which of the following agents is a nonnucleoside reverse transcriptase inhibitor used to treat HIV

infection? a. Saquinavir b. Nevirapine c. Zidovudine d. Raltegravir ANS: B

Nevirapine is a nonnucleoside reverse transcriptase inhibitor specific for HIV-1. It inhibits the same enzymes as the nucleoside analogues but does not require bioactivation. Saquinavir is an HIV protease inhibitor. Zidovudine is a nucleoside reverse transcriptase inhibitor. Raltegravir is an integrase inhibitor.

DIF: Recall REF: Antiviral Agents (Acquired Immunodeficiency Syndrome [Nonnucleoside Reverse Transcriptase Inhibitors]) | p. 96 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27. HIV-2 is only transmitted a. from a woman to her child while the child is in the womb. b. via sexual intercourse. c. by intravenous substance abuse. d. by sharing of bodily fluids.

ANS: A

HIV-2 is different from HIV-1 in that it is only transmitted from a woman to her child while the child is in the womb. This particular form of the virus appears to be centralized in western Africa. HIV-1 is transmitted via sexual intercourse, sharing of bodily fluids, and intravenous substance abuse, and during pregnancy and childbirth.

DIF: Recall REF: Antiviral Agents (Acquired Immunodeficiency Syndrome [Nonnucleoside Reverse Transcriptase Inhibitors]) | p. 96 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 28. Which of the following groups of drugs used to treat HIV can interfere with the action of the HIV-

infected cells? a. Nucleoside reverse transcriptase inhibitors b. Nonnucleoside reverse transcriptase inhibitors c. Protease inhibitors d. Both A and B e. Both B and C

ANS: C

The difference between the protease inhibitors and the nucleoside analogs or nucleoside/nucleotide reverse transcriptase inhibitors is that the protease inhibitors can interfere with the action of the HIVinfected cells. Its adverse reactions include rash, hyperglycemia, and paresthesias. The remaining groups of drugs used to treat HIV do not interfere with the action of HIV-infected cells.

DIF: Application REF: Antiviral Agents (Acquired Immunodeficiency Syndrome [Protease Inhibitors]) | p. 96 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 29. Which of the following classes of drugs used to treat human immunodeficiency virus (HIV) block the

progression from HIV infection to AIDS by preventing the passage of the virus across the human cell membrane? a. Integrase inhibitor b. Nonnucleoside reverse transcriptase inhibitor c. Nucleoside/nucleotide reverse transcriptase inhibitor d. Entry inhibitor e. Protease inhibitor ANS: D

Entry or fusion inhibitors are used in combination with other antiretroviral drugs for the treatment of HIV infection. These drugs work by interfering with binding and fusion entry of an HIV virion into a human cell. These agents block the progression from HIV infection to AIDS. The other choices work by different means.

DIF: Comprehension REF: Antiviral Agents (Acquired Immunodeficiency Syndrome [Fusion/Entry Inhibitors]) | p. 96 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 30. What is integrase in the context of infection with human immunodeficiency virus? a. It measures the CD4 lymphocyte count to determine the health of the patient. b. It is a viral enzyme that inserts the viral genome into the DNA of the host cell. c. It prevents the cleavage of viral protein precursors needed to generate functional

structural proteins in and modulation of reverse transcriptase activity. d. It terminates the synthesis of viral DNA. ANS: B

Integrase is a viral enzyme. Since integration is an important process of the retroviral replication process, blocking it can halt further spread of the virus. Measurement of the CD4 lymphocyte count is used to determine the progression of HIV in a patient toward full-blown AIDS, but it does not involve integrase. Protease inhibitors such as saquinavir prevent the cleavage of viral protein precursors.

Nucleoside/nucleotide reverse transcriptase inhibitors such as zidovudine terminate the synthesis of viral DNA. DIF: Comprehension REF: Antiviral Agents (Acquired Immunodeficiency Syndrome [Integrase Inhibitors]) | p. 97 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 31. Which of the following two types of hepatitis account for almost two-thirds of all cases of hepatitis?

a. b. c. d.

A and B A and C B and C C and D

ANS: C

Hepatitis B and C are the most common causes of hepatitis. Hepatitis is characterized by liver inflammation and may present with either no symptoms or with very few symptoms. The remaining choices do not properly represent the types of hepatitis that account for almost two-thirds of all cases of hepatitis.

DIF: Recall OBJ: 4

REF: Antiviral Agents (Chronic Hepatitis) | p. 97 TOP: NBDHE, 6.0. Pharmacology

32. A person with hepatitis a. A b. B c. C d. D

is most likely to develop chronic hepatitis.

ANS: C

People with hepatitis C are most likely to develop chronic hepatitis. The remaining choices are not forms of hepatitis that are most likely to develop chronic hepatitis.

DIF: Comprehension REF: Antiviral Agents (Chronic Hepatitis) | p. 97 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 33. Which antifungal agent for oral candidiasis is available as an aqueous suspension? a. Clotrimazole b. Ketoconazole c. Fluconazole d. Nystatin ANS: D

Nystatin is available as an aqueous suspension, and also as vaginal tablets, cream, ointment, or pastilles. Clotrimazole is available as a troche, ketoconazole, and fluconazole are available as oral tablets.

DIF: Recall REF: Antifungal Agents (Nystatin) | p. 90 | Antifungal Agents (Imidazoles [Clotrimazole]) | pp. 90-91 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 34. Most antiviral agents are either purine or pyrimidine analogues that inhibit synthesis of a. tRNA. b. mRNA. c. rRNA. d. DNA. ANS: D

Most antiviral agents are either purine or pyrimidine analogues that inhibit DNA synthesis. Most antiviral agents inhibit DNA synthesis rather than RNA synthesis.

DIF: Comprehension REF: Antiviral Agents (Herpes Simplex) | p. 92 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 35. Which type of herpes virus is transmitted to humans primarily by a monkey bite? a. Herpes simplex type 1 b. Herpes simplex type 2 c. Herpes B virus d. Varicella-zoster ANS: C

Herpes B (Herpesvirus simiae) is transmitted through the bite of monkeys and is deadly to humans. All of these choices represent possibilities for the antiviral action of acyclovir, but it is herpes B that is transmitted through bites from monkeys.

DIF: Application OBJ: 2

REF: Antiviral Agents (Herpes Simplex [Acyclovir]) | p. 92 TOP: NBDHE, 6.0. Pharmacology

36. Topical acyclovir will prevent transmission of herpes labialis. Topical acyclovir will prevent

recurrence of herpes labialis. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement false, the second is true.

ANS: B

Topical acyclovir does not prevent the transmission of herpes labialis infection, and it does not prevent recurrence. Available literature does not support the use of topical acyclovir for management of herpes labialis in dentistry. No acyclovir products are approved for treatment of recurrent herpes labialis in the immunocompetent patient.

DIF: Comprehension REF: Antiviral Agents (Herpes Simplex [Acyclovir]) | pp. 92-93 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 37. Each of the following is a consequence of the interaction of interferon with cells except one. Which is

the exception? a. Alteration of the state of cellular differentiation b. Stimulation of oncogene expression c. Induction of gene transcription d. Inhibition of cellular growth ANS: B

Interferons will interfere with the expression of oncogenes. The other choices are all effects of interferon on cells. Other effects include: altering cell surface antigen expression, increasing phagocytic activity of macrophages, and augmenting the cytotoxicity of lymphocytes.

DIF: Comprehension

REF: Antiviral Agents (Chronic Hepatitis [Interferons]) | p. 97 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

38. A dental hygienist should receive postexposure prophylaxis within

hours following exposure to the HIV virus? a. 24 b. 48 c. 72 d. 96 e. Zero hours because the medication must be administered prior to exposure.

ANS: C

The sooner the better, but it should begin within 72 hours. The recommendation is within 72 hours.

The medication is not administered prior to exposure.

DIF: Recall REF: Antiviral Agents (Acquired Immunodeficiency Syndrome [Postexposure Prophylaxis]) | p. 97 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 39. Why would a patient ever take a vaginal tablet of nystatin orally? a. The vaginal tablet is dosed once per day, which is less frequently than the oral b. c. d. e.

pastille.

The vaginal tablet does not contain sugar.

The vaginal tablet does not require a prescription.

The vaginal tablet has better flavor than the oral tablet.

Only if they did not read the directions and did not know any better.

ANS: B

The vaginal tablet does not contain sugar. The aqueous suspension contains 50% sucrose. This can be important for a diabetic patient. The vaginal tablet for oral use is dosed 4 times per day. Nystatin requires a prescription regardless of the delivery form. The vaginal tablet is not flavored for oral use.

DIF: Application OBJ: 1

REF: Antifungal Agents (Nystatin) | p. 90 TOP: NBDHE, 6.0. Pharmacology

MULTIPLE RESPONSE 1. Nystatin is available in the form of a(n)

apply.) a. intramuscular injection b. 200-mg oral tablet c. aqueous suspension d. pastille ANS: C, D

for the treatment of oral candidiasis. (Select all that

Nystatin is available as an aqueous suspension, vaginal tablet, cream, ointment, and pastille. The aqueous suspension (100,000 U/ml) contains 50% sucrose. The aqueous solution should be used as a rinse and expectorated. The aqueous solution can be frozen and used as a popsicle. Swallowing the solution will not cause harm, as it is not absorbed by the gastrointestinal tract and it will not eradicate pharyngeal candidiasis either. Nystatin pastilles are licorice-flavored, are rubbery, and also contain sugar. Nystatin is not available for injection. It is available for oral administration as a suspension or pastille. The vaginal tablets can be used orally.

DIF: Recall OBJ: 1

REF: Antifungal Agents (Nystatin) | p. 90 TOP: NBDHE, 6.0. Pharmacology

2. Which of the following describes ketoconazole? (Select all that apply.) a. It binds to sterols in the fungal cell membrane. b. It requires an acidic environment for adequate systemic absorption. c. It may interact with warfarin. d. It is the drug of choice for treatment of tinea.

ANS: B, C

An acidic environment is required for the adequate systemic absorption of ketoconazole. Medications that interfere with the normal production of stomach acid, such as histamine-2 (H2)-blockers or H2receptor antagonists and proton pump inhibitors, could theoretically reduce the absorption of ketoconazole. Ketoconazole and other imidazoles interact with warfarin. This may increase warfarin blood levels and increase the risk for bleeding. Incorrect choices: The imidazoles inhibit the C-14 demethylation of lanosterol, an ergosterol precursor. By interfering with the synthesis of ergosterol membrane permeability is altered and purine transport inhibited. Ketoconazole is not the drug of choice for the treatment of tinea unless traditional agents have failed.

DIF: Comprehension REF: Antifungal Agents (Imidazoles [Ketoconazole]) | p. 92 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. Which of the following types of HIV drugs are also used to treat hepatitis B? (Select all that apply.) a. Nucleoside analog b. Nonnucleoside analogs or nonnucleoside reverse transcriptase inhibitor c. Nucleoside/nucleotide reverse transcriptase inhibitors d. Fusion/entry inhibitor e. Integrase inhibitor ANS: A, C

Several oral nucleoside/nucleotide analogs are available for the treatment of chronic hepatitis B. The protease inhibitors boceprevir and telaprevir were approved by the Food and Drug Administration (FDA) for use in combination with peginterferon and ribavirin for the treatment of chronic hepatitis C genotype1 infection. The remaining types of HIV drugs are not currently used to treat hepatitis B. DIF: Application REF: Antiviral Agents Acquired Immunodeficiency Syndrome (Table 8.5: Examples of Drugs Used to Treat Human Immunodeficiency Virus) | p. 95 | Antiviral Agents (Chronic Hepatitis [Nucleoside/Nucleotide Analogs] [Table 8.7: Drugs for Treating Chronic Hepatitis]) | p. 98 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology

4. The most common FDA-approved use of interferons is for the treatment of which of the following?

(Select all that apply.) a. Hepatitis B b. Hepatitis C c. Multiple sclerosis d. Emphysema e. Sarcoidosis ANS: A, B

The FDA has approved the use of interferon alfa for the treatment of chronic hepatitis B and hepatitis C. The remaining choices are not FDA approved uses for interferons.

DIF: Comprehension REF: Antiviral Agents (Chronic Hepatitis [Interferons]) | p. 97 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

TRUE/FALSE 1. Oral candidiasis infections are often treatable with oral antifungal lozenges and rinses.

ANS: T

Preparations of nystatin and clotrimazole are available to treat oral candidiasis in a nonsystemic manner.

DIF: Recall REF: Antifungal Agents (Nystatin) | p. 90 | Antifungal Agents (Imidazoles [Clotrimazole]) | pp. 90-91 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Most antiviral agents are protein synthesis inhibitors.

ANS: F

Most antiviral agents are either purine or pyrimidine analogues that inhibit DNA synthesis.

DIF: Recall OBJ: 2

REF: Antiviral Agents (Herpes Simplex) | p. 92 TOP: NBDHE, 6.0. Pharmacology

3. No acyclovir products are approved for the treatment of recurrent herpes labialis in the

immunocompetent patient.

ANS: T

Although available literature does not support the use of topical acyclovir for management of herpes labialis in dentistry, it is used extensively.

DIF: Recall OBJ: 2

REF: Antiviral Agents (Herpes Simplex [Acyclovir]) | pp. 92-93 TOP: NBDHE, 6.0. Pharmacology

4. Topical acyclovir can prevent the recurrence of herpes labialis.

ANS: F

Topical acyclovir does not prevent the transmission of infection, and it does not prevent recurrence.

DIF: Recall OBJ: 2

REF: Antiviral Agents (Herpes Simplex [Acyclovir]) | p. 92 TOP: NBDHE, 6.0. Pharmacology

5. All currently available interferons are parenteral.

ANS: T

Interferons are used parenterally, and injection site reactions, such as necrosis, can occur.

DIF: Recall OBJ: 4

REF: Antiviral Agents (Chronic Hepatitis [Interferons]) | p. 97 TOP: NBDHE, 6.0. Pharmacology

Chapter 09: Local Anesthetics Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Antianxiety agents are most commonly administered orally because the effective dose of a particular

antianxiety agent is very predictable. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Orally administered drugs are more commonly used than intravenous agents to provide relaxation for the anxious patient. However, the dose of a particular antianxiety agent effective for a particular patient is quite variable, involving both intrapatient and interpatient variation. Intravenous (IV) administration is used infrequently because it requires more training and experience that most general dentists possess. Most states require a separate certificate to administer IV agents or to provide conscious sedation, and the malpractice insurance is much more expensive. Although orally administered sedatives provide inconsistent or poorly predictable results, practitioners should become familiar with one or two drugs and use them repeatedly.

DIF: Comprehension REF: Introduction | p. 100 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following agents are the most commonly prescribed type of antianxiety drugs? a. Nonbenzodiazepine-nonbarbiturate sedative-hypnotics b. Nonbenzodiazepine-nonbarbiturate receptor agonists c. Benzodiazepines d. Barbiturates ANS: C

The benzodiazepines are the most commonly prescribed antianxiety drugs. In 2019, 92 million benzodiazepines were dispensed from retail and mail order pharmacies. The members of this group differ mainly in their onset and duration of action, dose, and dose forms available.

Nonbenzodiazepine-nonbarbiturate sedative-hypnotics are being used much less often, especially since chloral hydrate is no longer available in the United States. Buspirone is currently the only member of this anxiolytic group. Nonbenzodiazepine-benzodiazepine receptor agonists are used to treat insomnia rather than anxiety. Because benzodiazepines have a much more acceptable safety profile, they have almost completely replaced barbiturates in clinical use for treating anxiety and insomnia.

DIF: Recall REF: Benzodiazepines | p. 101 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

3. Which is the primary adverse reaction associated with the use of benzodiazepines for conscious

sedation? a. Anterograde amnesia b. Retrograde amnesia c. Spiking blood pressure d. Respiratory depression ANS: D

Usual doses of benzodiazepines have no adverse effect; however, diazepam has occasionally been reported to cause respiratory depression. Amnesia is considered to be an advantage rather than adverse reaction. The relief of anxiety due to administration of benzodiazepines may be associated with a decrease in blood pressure and pulse rate.

DIF: Comprehension REF: Mechanism of Action (Adverse Reactions [Respiratory Effects]) | p. 103 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. Which benzodiazepine is preferred for use in elderly patients? a. Benzodiazepines that require phase I metabolism and not phase II metabolism b. Benzodiazepines that require phase II metabolism and not phase I metabolism c. Benzodiazepines that require both phase I and phase II metabolism d. Benzodiazepines that require neither phase I nor phase II metabolism ANS: B

Phase II drug metabolism (conjugation) is less affected by age than phase I drug metabolism. Some benzodiazepines, such as lorazepam, oxazepam, and temazepam, do not require phase I metabolism to become inactivated in the body. Caution should still be used when prescribing these drugs for elderly persons. Phase I metabolism is decreased in the elderly, in patients taking certain drugs that inhibit hepatic metabolism, and in the presence of hepatic disease. All benzodiazepines must be metabolized by either phase II metabolism or phase I followed by phase II metabolism.

DIF: Application OBJ: 2

REF: Benzodiazepines (Pharmacokinetics) | p. 102 TOP: NBDHE, 6.0. Pharmacology

5. Some benzodiazepines are transformed in the body to active metabolites. The active metabolites are

formed by phase II drug metabolism. a. Both statements are true.

b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Phase I drug metabolism transforms some benzodiazepines to active metabolites. Phase I rather than phase II metabolism results in active metabolites that can accumulate with repeated administration.

DIF: Comprehension REF: Benzodiazepines (Pharmacokinetics) | p. 102 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. Benzodiazepines enhance or facilitate the action of the neurotransmitter a. acetylcholine. b. epinephrine. c. -aminobutyric acid (GABA). d. serotonin.

ANS: C

Benzodiazepines enhance or facilitate the action of the neurotransmitter GABA, a major inhibitory transmitter in the central nervous system (CNS). It acts in the limbic, thalamic, cortical, and hypothalamic levels of the CNS. Benzodiazepines act as agonists at the benzodiazepine receptor site, and reduce the symptoms of anxiety. Benzodiazepines do not enhance the function of the remaining listed neurotransmitters. Acetylcholine has been identified as the principal neurotransmitter of the parasympathetic autonomic nervous system. Norepinephrine and epinephrine are the major neurotransmitters of the sympathetic autonomic nervous system. Serotonin is a neurotransmitter that is thought to be involved with sleep cycles.

DIF: Recall REF: Mechanism of Action | p. 102 TOP: NBDHE, 6.0. Pharmacology 7. The clinical effects of benzodiazepines in humans are a. drowsiness and sleep b. drowsiness and anxiety reduction c. anxiety reduction and panic reduction d. anxiety reduction and sleep

OBJ: 2

at lower doses.

ANS: C

The clinical effects of benzodiazepines in humans are anxiety and panic reduction at lower doses.

Repeated doses of benzodiazepines reduce rapid-eye-movement sleep. Usual doses produce a marked reduction in stages 3 and 4 sleep (deep sleep), which, after long-term use, can interfere with restorative sleep. Benzodiazepines produce drowsiness and sleep at higher doses.

DIF: Recall REF: Mechanism of Action (Pharmacologic Effects [Behavioral Effects]) | p. 102 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. Benzodiazepines are indicated for epilepsy because they a. reduce the electrical activity in the seizure focus. b. limit the spread of abnormal activity to other parts of the brain. c. produce analgesia so the patient does not feel any pain.

d. reduce hallucinations.

ANS: B

The benzodiazepines prevent the spread of abnormal electrical activity to tissues surrounding the anatomic seizure focus (when such a focus exists). Benzodiazepines have little effect on the discharges at the seizure focus itself. They have antiseizure activity by increasing the seizure threshold. They are not administered to produce analgesia or to reduce hallucinations.

DIF: Comprehension REF: Mechanism of Action (Pharmacologic Effects [Antiseizure Effects]) | p. 102 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. When benzodiazepines are used in dentistry to produce conscious sedation, the appearance of a. b. c. d.

is used as an initial endpoint for the dose administered. flushed skin miosis ptosis rapid eye movement

ANS: C

The appearance of ptosis is used as an initial endpoint for the dose administered. Ptosis is drooping of the upper eyelid. When benzodiazepines are used in dentistry to produce conscious sedation, this side effect of CNS depression is used as the primary effect. The amount of the benzodiazepine used to provide conscious sedation is titrated to the patient’s response. The remaining choices do not represent an initial endpoint for the dose administered. Repeated doses of benzodiazepines reduce rapid eye movement (REM) sleep.

DIF: Recall REF: Mechanism of Action (Adverse Reaction [Central Nervous System Effects]) | p. 102 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 10. Which of the following parenteral benzodiazepines seems to have the greatest likelihood to produce

amnesia? a. Diazepam (Valium) b. Midazolam (Versed) c. Triazolam (Halcion) d. Eszopiclone (Lunesta) ANS: C

Oral triazolam seems to have a greater likelihood to produce amnesia than other oral benzodiazepines.

Clinical use has produced episodes of amnesia that can sometimes last several hours. These episodes may occur with several of the benzodiazepines. Patients should be warned not to sign important papers or make important decisions after benzodiazepines are administered. Parenteral benzodiazepines, such as diazepam and midazolam, produce amnesia beginning when the drug is taken; however, these choices are not the benzodiazepine that seems to have the greatest likelihood to produce amnesia.

Eszopiclone is not a benzodiazepine, it is a nonbenzodiazepine-benzodiazepine receptor agonist and is used to produce sleep.

DIF: Recall REF: Mechanism of Action (Adverse Reactions [Anterograde Amnesia]) | pp. 102-103

OBJ: 2

TOP: NBDHE, 6.0. Pharmacology

11. The therapeutic index of benzodiazepines is a. wider than b. narrower than c. the same as d. None of the above are correct

that of the barbiturates.

ANS: A

The difference between the effective and toxic doses of the benzodiazepines is greater than that for the barbiturates. The therapeutic index of benzodiazepines is wide unless they are mixed with alcohol.

Overdose poisoning with these drugs has been rare and appears to be difficult to achieve when used alone, although apnea has rarely been reported. One is less susceptible to overdose with benzodiazepines as compared with barbiturates because the benzodiazepines have a wider therapeutic index than barbiturates.

DIF: Recall OBJ: 2 12. a. b. c. d.

REF: Mechanism of Action (Abuse and Tolerance [Overview]) | p. 103 TOP: NBDHE, 6.0. Pharmacology

may be used to reverse some of the effects of a benzodiazepine.

Ramelteon (Rozerem) Phenobarbital (Luminal) Flumazenil (Romazicon) Carisoprodol (Soma)

ANS: C

Flumazenil (Romazicon), a benzodiazepine antagonist available for IV administration, may be used to reverse some of the effects of a benzodiazepine. It has been shown to reverse the sedating and psychomotor effects, but reversing the respiratory depression produced by the benzodiazepines is incomplete. The amnesia is not consistently reversed. Ramelteon (Rozerem) is a melatonin receptor agonist. Phenobarbital (Luminal) is a barbiturate. Carisoprodol (Soma) is a centrally acting skeletal muscle relaxant.

DIF: Recall REF: Mechanism of Action (Abuse and Tolerance [Treatment of Overdose]) | p. 103 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. Which of the following agents may decrease the effectiveness of benzodiazepines? a. Tobacco b. Omeprazole c. Valproic acid d. Fluoxetine ANS: A

Smoking tobacco reduces the effectiveness of the benzodiazepines by stimulating the hepatic microsomal enzymes in the liver, which increases its rate of metabolism. A higher dose of a benzodiazepine would then be required to produce the same effect. Omeprazole can inhibit the metabolism of benzodiazepines. Valproic acid may displace diazepam from binding sites, increasing free circulating levels. Fluoxetine can increase diazepam blood levels by altering the clearance of diazepam from the body.

DIF: Recall OBJ: 2 14.

REF: Mechanism of Action (Abuse and Tolerance [Drug Interactions]) | p. 104 TOP: NBDHE, 6.0. Pharmacology

is an intravenously (IV) administered benzodiazepine that is used for conscious sedation in oral health care. a. Chlordiazepoxide (Librium) b. Lorazepam (Ativan) c. Triazolam (Halcion) d. Midazolam (Versed) ANS: D

Midazolam is an IV benzodiazepine used for conscious sedation in dental offices. Only dentists trained in its administration can use it. IV sedation allows the dentist to regulate the level of sedation during the procedure. Oral benzodiazepines can be used and are usually administered to the patient 15 to 30 minutes prior to the dental procedure. The remaining choices are not IV benzodiazepines that are used for sedation in oral health care.

DIF: Comprehension REF: Mechanism of Action (Medical Uses [Conscious Sedation]) | p. 104 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 15. Which of the following sleep stages is enhanced with the use of benzodiazepines? a. Latency period b. Rapid eye movement (REM) sleep c. Nonrapid eye movement (NREM) sleep stages 3 and 4 d. Nonrapid eye movement (NREM) sleep stage 2 ANS: D

Benzodiazepines reduce the latency period, REM sleep, and NREM sleep stages 3 and 4, while increasing stage 2. When benzodiazepines have been used chronically and are discontinued, rebound REM sleep often occurs, resulting in an increase in vivid dreams. The remaining choices or sleep stages are not increased when benzodiazepines are used.

DIF: Comprehension REF: Mechanism of Action (Medical Uses [Insomnia Management]) | p. 104 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 16. The benzodiazepines are preferable to the barbiturates as hypnotics because the risk of physical

addiction or serious poisoning is much less. The efficacy of the benzodiazepines in the treatment of chronic insomnia has been demonstrated for longer than 2 years. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

The benzodiazepines are preferable to the barbiturates as hypnotics because the risk of physical addiction or serious poisoning is much less. However, the efficacy of the benzodiazepines in the treatment of chronic insomnia has not been demonstrated past 1 month. Benzodiazepines are much safer than barbiturates because the therapeutic index is much wider. In most instances, excessively large doses must be ingested to produce respiratory or central vasomotor depression. The efficacy of the benzodiazepines has not been demonstrated past 1 month. Nonaddicting agents, such as trazodone (Desyrel), a serotonin modulator, may be useful in the treatment of insomnia, and no tolerance or dependence is produced even with chronic use.

DIF: Comprehension REF: Mechanism of Action (Medical Uses [Insomnia Management]) | p. 104 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 17. All of the following habits should be followed to minimize insomnia except for one. Which one is the

exception? a. Light snack (warm milk) at bedtime b. Awake at 6 AM even if sleep only began at 5 AM c. Exercise within 3 hours of bedtime d. Remaining in bed no longer than 20 minutes without sleeping e. No smoking within 8 hours of bedtime ANS: C

Exercise during the day, but not within 3 hours of bedtime. A light snack is calming. Regular awakening is important to establish a routine. Extended time in bed without sleep alters the psychologic purpose of being in bed—to sleep. Smoking may reduce calmness needed for sleeping.

DIF: Comprehension REF: Mechanism of Action (Medical Uses [Insomnia Management] [Box 9.1: Nonpharmacologic Management of Sleep Disorders]) | p. 104 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 18. Which of the following benzodiazepines is the drug of choice for treatment of repetitive, intractable

seizures that require IV therapy? a. Chlordiazepoxide (Librium) b. Diazepam (Valium) c. Zolpidem (Ambien) d. Eszopiclone (Lunesta) ANS: B

Diazepam (Valium) or lorazepam (Ativan) are the drugs of choice for treatment of repetitive, intractable seizures (status epilepticus) that require IV therapy. They also are used for treatment of seizures caused by local anesthetic toxicity. Orally administered diazepam is of little value, even as a maintenance anticonvulsant. Oral clonazepam is used as an adjunct to other anticonvulsants for some difficult-to-control types of seizures. Chlordiazepoxide is not used for status epilepticus that requires IV therapy. Zolpidem and eszopiclone are not benzodiazepines. They are categorized as nonbenzodiazepine-benzodiazepine receptor agonists.

DIF: Recall REF: Mechanism of Action (Medical Uses [Treatment of Epilepsy (Seizures)]) | pp. 104-105 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

19. Which of the following agents used for dental anxiety has a fast onset and short half-life? a. Triazolam b. Diazepam c. Lorazepam d. Alprazolam ANS: A

Triazolam has a fast onset and short half-life. Diazepam has a very fast onset but long half-life.

Lorazepam and Alprazolam have immediate onset but relatively short half-lives.

DIF: Application REF: Benzodiazepines (Table 9.1: Benzodiazepines and Miscellaneous Sedative-Hypnotic Agents) | p. 101 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 20. Barbiturates act on nerves by enhancing the binding of which neurotransmitter to its receptor? a. Glutamate b. Serotonin c. GABA d. Chloride ANS: C

Barbiturates produce their effect by enhancing GABA receptor binding. They prolong the opening of the GABA receptor-associated chloride channels. Barbiturates do not affect the binding of glutamate or serotonin to their receptors. Chloride is not a neurotransmitter.

DIF: Recall OBJ: 2

REF: Barbiturates (Mechanism of Action) | p. 106 TOP: NBDHE, 6.0. Pharmacology

21. Although a lethal dose of barbiturates can only be approximated, severe poisoning will follow the

ingestion of a. 5 b. 10 c. 15 d. 20

times the hypnotic dose.

ANS: B

Severe poisoning will follow the ingestion of 10 times the hypnotic dose of barbiturates, and life is seriously threatened when more than 15 times the hypnotic dose is consumed. The cause of death is respiratory failure when an overdose occurs. The treatment includes conservative management and treatment of specific symptoms. Barbiturates have a narrow therapeutic index (TI), meaning the difference between an effective dose and a lethal dose is relatively small. Therefore, it is very important to know the TI for barbiturates.

DIF: Recall OBJ: 2

REF: Barbiturates (Adverse Reactions [Acute Poisoning]) | p. 106 TOP: NBDHE, 6.0. Pharmacology

22. Chronic use of barbiturates can lead to a. both physical and psychologic b. physical but not psychologic c. psychologic but not physical

dependence.

d. neither physical nor psychologic ANS: A

Physical dependence refers to the altered physiologic state that results from constantly increasing drug concentrations. The presence of physical dependence is established by withdrawal or abstinence syndrome. Psychologic dependence is a state of mind in which a person believes that he or she is unable to maintain optimal performance without having taken a drug. Chronic use of barbiturates can lead to both physical and psychologic dependence. Long-term use produces a state similar to alcohol intoxication. The barbiturate addict becomes progressively depressed and is unable to function.

Tolerance develops to most effects of barbiturates but not to the lethal dose.

DIF: Recall OBJ: 2

REF: Barbiturates (Long-Term Use) | p. 106 TOP: NBDHE, 6.0. Pharmacology

23. The use of barbiturates is absolutely contraindicated in patients with a positive family history of a. high blood pressure. b. diabetes. c. porphyria. d. adrenal insufficiency.

ANS: C

The use of barbiturates is absolutely contraindicated in patients with intermittent porphyria or a positive family history of porphyria because barbiturates can stimulate and increase the synthesis of porphyrins, which are already at an excessive level in this metabolic disease. In fact, the barbiturates have been reported to precipitate an acute attack of porphyria. The remaining choices are not absolute contraindications to the use of barbiturates.

DIF: Recall OBJ: 2

REF: Barbiturates (Contraindications) | p. 106 TOP: NBDHE, 6.0. Pharmacology

24. Barbiturates reduce the effects of the following drugs except which one? a. Propoxyphene b. Chlorpromazine c. Warfarin d. Phenytoin e. Doxycycline ANS: A

Disulfiram, propoxyphene, and phenytoin will all enhance the effect of a barbiturate. Barbiturates may increase the metabolism of others, leading to lower blood concentrations of these drugs, and reducing their effects.

DIF: Comprehension REF: Barbiturates (Drug Interactions [Box 9.3: Barbiturate Drug Interactions]) | pp. 106-107 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 25. Which of the following is the longest acting barbiturate? a. Methohexital (Brevital) b. Pentobarbital (Nembutal) c. Secobarbital (Seconal)

d. Phenobarbital (Luminal) ANS: D

Phenobarbital (Luminal) and mephobarbital (Mebaral) are long-acting barbiturates. Methohexital (Brevital) is an ultrashort-acting barbiturate. Pentobarbital (Nembutal) and secobarbital (Seconal) are short-acting barbiturates.

DIF: Comprehension REF: Barbiturates (Table 9.2: Barbiturates) | p. 105 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 26. Which agent has selective anxiolytic action without hypnotic, anticonvulsant, or muscle-relaxant

properties? a. Zolpidem b. Flumazenil c. Meprobamate d. Buspirone e. Tizanidine ANS: D

Buspirone is unique in structure and action. The pharmacologic effect of buspirone is called anxioselective because of its selective anxiolytic action without hypnotic, anticonvulsant, or musclerelaxant properties. Zolpidem is anxiolytic and hypnotic. Flumazenil antagonizes the above effects by drugs that bind to benzodiazepine receptors. Meprobamate has the full spectrum of properties found in barbiturates. Tizanidine is a muscle relaxant and not an anxiolytic.

DIF: Recall REF: Nonbenzodiazepine-Nonbarbiturate Sedative-Hypnotics (Buspirone) | p. 107 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27. Which of the following nonbenzodiazepine-benzodiazepine receptor agonists has the shortest half-life? a. Zolpidem (Ambien) b. Zaleplon (Sonata) c. Eszopiclone (Lunesta) ANS: B

Zaleplon is a rapid-acting hypnotic that is less potent and has a shorter duration of action than zolpidem. Zolpidem has a longer duration of action than zaleplon. Eszopiclone has the longest half-life of these three agents.

DIF: Application REF: Nonbenzodiazepine Receptor Hypnotics (Zaleplon) | p. 107 | Nonbenzodiazepine Receptor Hypnotics (Eszopiclone) | p. 107 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 28. Which of the following agents is a melatonin receptor agonist? a. Buspirone b. Zaleplon c. Chloral hydrate d. Ramelteon e. Tizanidine ANS: D

Ramelteon binds to melatonin type 1 (MT1) and type 2 (MT2) receptors. Buspirone is a 5HT1A agonist, zaleplon binds to benzodiazepine receptors, chloral hydrate has an unknown mechanism, and tizanidine is a centrally acting a-adrenergic agonist.

DIF: Recall OBJ: 4

REF: Melatonin Receptor Agonist | p. 107 TOP: NBDHE, 6.0. Pharmacology

29. Which of the following is considered to be the strongest centrally acting skeletal muscle relaxant? a. Carisoprodol (Soma) b. Methocarbamol (Robaxin) c. Cyclobenzaprine (Flexeril) d. Orphenadrine (Norflex) ANS: C

Cyclobenzaprine (Flexeril) is considered to be the strongest muscle relaxant. Because sedation occurs in approximately 40% of the patients taking cyclobenzaprine, it is the most sedating muscle relaxant. It also is most likely to produce xerostomia with an incidence of 30%. The remaining choices do not represent the strongest muscle relaxant.

DIF: Recall REF: Centrally Acting Muscle Relaxants (Individual Centrally Acting Muscle Relaxants) | p. 108 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 30. Which of the following muscle relaxants has peripheral rather than central action? a. Carisoprodol b. Cyclobenzaprine c. Tizanidine d. Baclofen e. Dantrolene ANS: E

Dantrolene affects the contractile response of the skeletal muscle by acting directly on the muscle itself. Carisoprodol, cyclobenzaprine, tizanidine, and baclofen all act on the CNS (brain and spinal cord) to produce their muscle relaxant properties.

DIF: Application OBJ: 6

REF: Miscellaneous Agents (Dantrolene) | p. 109 TOP: NBDHE, 6.0. Pharmacology

31. What percentage of Americans only seek oral health care when absolutely necessary? a. 0% b. 5% c. 10% d. 20% ANS: D

Many patients who require dental care never go to the dental office because of fear and apprehension.

Almost 20% of Americans seek oral care only when absolutely necessary, and approximately 7% refuse to seek any dental care due to fear.

DIF: Recall

REF: Introduction | p. 100

OBJ: 1

TOP: NBDHE, 6.0. Pharmacology 32. A sedative-hypnotic agent can produce varying degrees of central nervous system (CNS) depression.

The same drug may be either a sedative or a hypnotic. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: A

The degree of CNS depression and whether the drug is a sedative or hypnotic is dependent on the dose.

A small dose causes mild CNS depression and has some anxiolytic effect. A larger dose of the same drug produces greater CNS depression.

DIF: Comprehension REF: Definitions | p. 100 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 33. Most patients with generalized anxiety disorder and panic attacks are being treated with a. benzodiazepines. b. barbiturates. c. nonbenzodiazepine-nonbarbiturate sedative-hypnotics. d. antidepressants.

ANS: D

These patients are now being treated with antidepressant drugs. These are common indications for the use of benzodiazepines in general medicine; however, their use is limited due to their potential for abuse and dependence.

DIF: Recall OBJ: 2

REF: Mechanism of Action (Medical Uses [Anxiety Control]) | p. 104 TOP: NBDHE, 6.0. Pharmacology

34. Which is best for all types of anxiety and muscle strain? a. Barbiturates b. Meprobamate c. Benzodiazepines d. Placebo ANS: C

Many well-controlled clinical trials have shown the antianxiety effects of benzodiazepines are better than those of placebo, barbiturates, and meprobamate. Benzodiazepines are safe and effective for patients being treated for social or situational anxiety.

DIF: Recall OBJ: 2

REF: Mechanism of Action (Medical Uses [Anxiety Control]) | p. 104 TOP: NBDHE, 6.0. Pharmacology

35. What should be done once a patient being treated with a benzodiazepine for “dental appointment”

insomnia sees there is no reason to fear the appointment? a. Cut the dose by one-half. b. Switch to a nonbenzodiazepine, benzodiazepine receptor agonist such as eszopiclone.

c. Utilize nonpharmacologic sleep measures prior to the next appointment. d. Don’t make any changes in the prescription.

ANS: C

Once the patient sees there is no reason to fear the appointment, nonpharmacologic sleep measures should be tried before the next appointment. The recommendation is to administer the pharmacologic help the patient needs for the first appointment, then try weaning them off the medication by using nonpharmacologic sleep measures.

DIF: Comprehension REF: Benzodiazepines (Medical Uses [Insomnia Management]) | p. 104 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 36. Each of the following is true of melatonin except one. Which is the exception? a. Melatonin is a naturally occurring hormone. b. Melatonin is a scheduled drug that requires a prescription. c. Melatonin may cause daytime sedation. d. Melatonin has been shown to have no benefit over a placebo in several clinical

trials.

ANS: B

Melatonin is available without a prescription and is sold as a food supplement or natural product.

Melatonin is synthesized by the pineal gland. Melatonin can cause daytime sedation, grogginess in the morning, depression, headache, stomach cramps, and irritability. Several clinical trials have found that melatonin shows no benefit over a placebo.

DIF: Comprehension REF: Melatonin | p. 108 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 37. Suvorexant (Belsomra) works by a. facilitating the action of -aminobutyric acid (GABA). b. blocking orexin neuropeptides from binding to their receptors. c. enhancing GABA-receptor binding. d. binding to serotonin in the CNS. ANS: B

Suvorexant and lemborexant are the first in a new class of drugs to treat insomnia. Once orexin neuropeptides are signaled its neuropeptides maintain wakefulness. Benzodiazepines facilitate the action of GABA. Barbiturates work by enhancing GABA-receptor binding. Buspirone appears to work by interacting with serotonin, dopamine, and cholinergic and -adrenergic receptors.

DIF: Comprehension REF: Orexin Receptor Antagonist | p. 108 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 38. The nonbenzodiazepine receptor hypnotics are used to treat a. panic attacks. b. generalized anxiety. c. insomnia. d. seizures.

ANS: C

Zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) are used to treat insomnia. They decrease sleep latency with little effect on sleep stages. They are controlled substance schedule IV and have the potential to cause both physical and psychological dependence.

DIF: Comprehension REF: Nonbenzodiazepine Receptor Hypnotics | p. 107 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Once a benzodiazepine is absorbed, the rate at which it reaches its site of action depends on which of

the following? (Select all that apply.) a. Lipid solubility b. Protein binding c. Ionization d. First-order kinetics ANS: A, B, C

Once a benzodiazepine is absorbed, the rate at which it crosses into the cerebrospinal fluid through the blood-brain barrier is dependent on protein binding, lipid solubility, and the ionization constant of the compound. First-order kinetics is a mathematical representation of the way in which drugs are removed from the body.

DIF: Comprehension REF: Benzodiazepines (Pharmacokinetics) | pp. 101-102 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following statements are true concerning administration of benzodiazepines and

pregnancy? (Select all that apply.) a. An increased risk of congenital malformation in infants of mothers taking benzodiazepines in the first trimester has been reported. b. Benzodiazepines do not cross the placental barrier. c. Near-term administration of benzodiazepines to the mother has resulted in floppy infant syndrome. d. The administration of benzodiazepines is not a concern during pregnancy.

ANS: A, C

An increased risk of congenital malformation in infants of mothers taking benzodiazepines in the first trimester has been reported. Near-term administration of benzodiazepines to the mother has resulted in floppy infant syndrome. Because these agents are seldom absolutely needed (except for epilepsy), they should be avoided in women who are or may become pregnant and in nursing mothers. The first trimester, often before the patient knows that she is pregnant, is the time benzodiazepines are more likely to be teratogenic or cause problems in the fetus.

DIF: Comprehension REF: Mechanism of Action (Adverse Reactions [Pregnancy and Lactation Considerations]) | p. 103 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 3. Which of the following are rationales for the use of analgesic-sedative combinations? (Select all that

apply.)

a. Relief of both anxiety and pain is often required in one patient. b. Sedatives interfere with analgesic agents. c. Sedatives may induce excitation when given without an analgesic to patients with

uncontrolled pain. d. Anxiety can raise the pain threshold.

ANS: A, C

The use of an analgesic and a sedative-hypnotic agent to provide concomitant sedation and analgesia is rational for several reasons. In a dental patient in whom anxiety is magnifying the pain reaction, prescribing a combination agent might be useful. Sedatives do not provide analgesia. Use of a sedative without adequate pain control may cause the patient to become highly excited and act irrationally.

Sedatives potentiate analgesic agents. Anxiety can lower the pain threshold.

DIF: Application REF: General Comments About Antianxiety Agents (Analgesic-Sedative Combinations [Box 9.4: Rationale for Use of Analgesic-Sedative Combinations]) | p. 109 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Anxiety control is only necessary for the first third of a dental appointment.

ANS: F

A dental practitioner who decides that anxiety control is only necessary for the first third of a dental appointment does not understand patient anxiety and its treatment.

DIF: Recall REF: Introduction | p. 100 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. Use of antianxiety agents in the dentist’s office should be discouraged because it encourages addiction.

ANS: F

A common misconception is that dental patients who express anxiety are just “looking for drugs.” The average dental patient who is being treated for dental anxiety during the appointment does not get the opportunity to abuse antianxiety agents. The appropriate use of antianxiety agents might encourage more patients to seek needed dental treatment.

DIF: Recall REF: Introduction | p. 100 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. Benzodiazepines are contraindicated in wide-angle glaucoma.

ANS: F

Benzodiazepines are contraindicated in angle-closure (narrow-angle) glaucoma and can produce other visual changes such as diplopia, nystagmus, and blurred vision. They may be used in wide-angle glaucoma, which is the most common kind of glaucoma.

DIF: Recall OBJ: 2

REF: Mechanism of Action (Adverse Reactions [Visual Effects]) | p. 103 TOP: NBDHE, 6.0. Pharmacology

4. Barbiturates have no significant analgesic effects.

ANS: T

Even doses that produce general anesthesia do not block the reflex response to pain. Patients in pain may become agitated and even delirious if barbiturates are administered without analgesic agents.

DIF: Recall OBJ: 2

REF: Barbiturates (Pharmacologic Effects [Analgesia]) | p. 106 TOP: NBDHE, 6.0. Pharmacology

5. Barbiturates can cause fetal harm if administered to a pregnant woman.

ANS: T

Barbiturates are contraindicated during pregnancy and breast-feeding.

DIF: Recall OBJ: 2

REF: Barbiturates (Adverse Reactions [Sedative or Hypnotic Doses]) | p. 106 TOP: NBDHE, 6.0. Pharmacology

6. Sedatives potentiate analgesic agents.

ANS: T

Sedatives may potentiate the effect of an analgesic taken concomitantly.

DIF: Recall REF: General Comments About Antianxiety Agents (Analgesic-Sedative Combinations [Box 9.4: Rationale for Use of Analgesic-Sedative Combinations]) | p. 109 | General Comments about Antianxiety Agents (Precautions) | p. 109 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology

Chapter 10: General Anesthetics Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. All of the following are characteristics of the ideal local anesthetic except a. sterilization by autoclave. b. slow onset. c. reversible. d. absence of local reactions.

ANS: B

For dentistry, a local anesthetic with a relatively rapid onset of action is desired so that the time between administration of the anesthetic and the commencement of a dental procedure can be minimized. Dental local anesthetic solutions are not sterilized by autoclave before use. Reversibility of the actions of the agent is necessary so that the patient can regain normal sensation in the tissue. Local reactions such as irritation are considered untoward and undesirable.

DIF: Recall REF: Ideal Local Anesthetic (Box 10.1: Properties of the Ideal Local Anesthetic) | p. 112 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology

2. Which portion of the chemical structure of a typical local anesthetic is considered lipophilic (lipid

soluble)? a. Aromatic nucleus b. Amino group c. Both A and B d. Neither A nor B ANS: A

The aromatic nucleus of the local anesthetic contains no positive or negative charges. This feature allows it to mix with and pass through lipid environments, such as the plasma membrane of a nerve cell. The amino group is considered water soluble or hydrophilic. At a certain pH, it can gain a charge, which will enhance its solubility in water and prohibit its solubility in lipids.

DIF: Recall REF: Chemistry | p. 111 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. The mechanism of local anesthetics involves action on a. myelinated nerve. b. axons. c. sodium channels. d. Both A and C. e. Both B and C. ANS: E

Local anesthetics bind to sodium channels found in the axons of nerves. They stop the propagation of the electrical impulse along the axon. Local anesthetics’ primary mode of action does not include myelinated nerve.

DIF: Application OBJ: 2

REF: Mechanism of Action (Action on Nerve Fibers) | pp. 111-112 TOP: NBDHE, 6.0. Pharmacology

4. Repolarization of a nerve occurs by a. influx of potassium. b. influx of sodium. c. efflux of potassium. d. efflux of calcium. e. None of the above.

ANS: C

During depolarization, an inward flux of sodium into the nerve occurs. During repolarization, an efflux of potassium out of the nerve occurs. The outward flow of potassium ions repolarizes the membrane and closes the sodium channels. The depolarization of a nerve involves a slow calcium influx. Calcium ions are bound to receptor sites within the ion channels of cell membranes during the resting stage of nerve conduction. Ca++ ions are displaced during depolarization and are believed to be the most significant factor responsible for the influx of sodium into the nerve.

DIF: Comprehension REF: Mechanism of Action (Action on Nerve Fibers) | p. 112 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

5. The following states are characteristics of the salt form of a local anesthetic except which one? a. Charged, cation (ionized) b. Alkaline c. Crystalline solid d. Stable ANS: B

The salt form of a local anesthetic is a form that has a positive charge and is complexed with an acid, such as hydrochloric acid, in the dose form. The positive charge is the result of the addition of a hydrogen ion to the molecule, making it an acid, not an alkaline base. The salt form more readily crystallizes, which creates a stable complex. The salt form of local anesthetic is crystalline solids, water soluble, stable, acidic, charged, cation (ionized), active at the site of action, and is the form present in the dental cartridge.

DIF: Recall REF: Mechanism of Action (Ionization Factors [Table 10.2] Properties of Base and Salt Forms of Local Anesthetics) | p. 113 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. In the presence of an acidic environment, such as infection or inflammation, the amount of free base is

reduced; therefore difficult. a. more; more b. more; less c. less; more d. less; less

of the local anesthetic is in the ionized form, making anesthesia

ANS: A

In an acidic environment, more of the local anesthetic is in the ionized form, making anesthesia more difficult. Other reasons include dilution by fluid, inflammation, and vasodilation in the area. The local anesthetic agent is a weak base. Bases are dissociated and nonionic in a basic environment, which means there is more free base to pass through the lipid cell membrane. Bases are associated and ionic in an acidic environment.

DIF: Comprehension REF: Mechanism of Action (Ionization Factors) | p. 112 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 7. The cationic form of a local anesthetic is needed to penetrate the nerve membrane, and the free base

form exerts blocking action by binding to the specific receptor site. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: B

The uncharged (nonionized) free base form of a local anesthetic is needed to penetrate the nerve membrane; however, the charged cationic (ionized) form exerts blocking action by binding to the specific receptor site. The cationic form is charged (ionized). It will not pass through the lipid nerve membrane. Remember that oil and water do not mix. The free base uncharged (nonionized) form is needed to pass through the membrane; however, it is the cationic form that is active at the site of action.

DIF: Comprehension REF: Mechanism of Action (Ionization Factors) | p. 112 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. Reducing the rate of systemic absorption of a local anesthetic is important when it is used in dentistry

because a. otherwise, too large an area would be anesthetized. b. if not, the anesthesia would not last long enough to complete a dental procedure. c. the chance of systemic toxicity is reduced. d. local anesthesia is associated with respiratory depression.

ANS: C

The chance of systemic toxicity is reduced with a reduced rate of absorption. A vasoconstrictor is often added to the local anesthetic to reduce the rate of absorption. The vasoconstrictor reduces the blood supply to the area, limits systemic absorption, and reduces systemic toxicity. The local anesthetic agents by themselves are vasodilators. This will increase the chances of systemic toxicity. Dental local anesthetics without vasoconstrictor have the shortest duration of action.

DIF: Comprehension REF: Pharmacokinetics (Absorption) | p. 113 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Addition of vasoconstrictor to local anesthetic (1) reduces blood supply to the area, (2) increases blood

supply to the area, (3) limits systemic absorption, (4) increases systemic absorption, (5) reduces systemic toxicity, and (6) increases systemic toxicity. Which of these are correct? a. 1, 3, 5 b. 1, 4, 5 c. 2, 3, 5 d. 2, 3, 6 e. 2, 4, 6 ANS: A

The vasoconstrictor reduces the blood supply to the area, limits systemic absorption, and reduces systemic toxicity. When a local anesthetic solution does not contain a vasoconstrictor, the anesthetic drug is more quickly removed from the injection site and distributed into systemic circulation than if the solution contained a vasoconstrictor. Plain anesthetics will exhibit a shorter duration of action and result in a more rapid buildup of a systemic blood level. Therefore, any anesthetic given without a vasoconstrictor is more likely to be toxic than those given with a vasoconstrictor. The remaining choices do not reflect the pharmacokinetic effects of adding a vasoconstrictor to a dental local anesthetic.

DIF: Comprehension REF: Pharmacokinetics (Absorption) | p. 113 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 10. Local anesthetics cross a. the placenta and blood-brain barrier. b. the placenta but not the blood-brain barrier. c. the blood-brain barrier but not the placenta. d. neither the placenta nor the blood-brain barrier.

ANS: A

Local anesthetics cross the placenta and blood-brain barrier. The other choices are not correct.

Although the placenta may act as a selective barrier against a few drugs, most drugs pass easily across the placental barrier. Lipid-soluble drugs penetrate this membrane most easily. The passage of a drug across the blood-brain barrier is related to the drug’s lipid solubility and degree of ionization.

DIF: Recall OBJ: 2

REF: Pharmacokinetics (Distribution) | p. 114 TOP: NBDHE, 6.0. Pharmacology

11. Amide local anesthetics are metabolized a. by being hydrolyzed by plasma pseudocholinesterases. b. primarily by the liver. c. in the spleen. d. minimally and are excreted virtually unchanged.

ANS: B

Amide local anesthetics are metabolized primarily by the liver. In severe liver disease, or with alcoholism, amides may accumulate and produce systemic toxicity. Esters are hydrolyzed by plasma pseudocholinesterases and liver esterases. Procaine is hydrolyzed to para-aminobenzoic acid (PABA), a metabolite that may be responsible for its allergic reactions.

DIF: Recall OBJ: 2

REF: Pharmacokinetics (Metabolism) | p. 114 TOP: NBDHE, 6.0. Pharmacology

12. Procaine (Novocaine) is metabolized primarily by the a. liver. b. lungs. c. plasma. d. kidneys.

ANS: C

Procaine is an ester local anesthetic and is metabolized primarily by plasma pseudocholinesterase.

Amide local anesthetics rely on cytochrome P450 mixed-function oxidases. These enzymes are found mainly in the liver, but they can be found in other tissues, such as the kidney and lungs.

DIF: Recall OBJ: 2

REF: Pharmacokinetics (Metabolism) | p. 114 TOP: NBDHE, 6.0. Pharmacology

13. Which of the following local anesthetic agents have the potential to cause methemoglobinemia as an

adverse effect? a. Prilocaine and lidocaine b. Lidocaine and mepivacaine c. Prilocaine and mepivacaine d. Prilocaine and articaine e. Mepivacaine and articaine ANS: D

Prilocaine (by virtue of its orthotoluidine metabolite) and articaine have been demonstrated to produce methemoglobinemia when administered in high doses. No reports have been documented of lidocaine or mepivacaine producing methemoglobinemia.

DIF: Comprehension REF: Pharmacokinetics (Metabolism) | p. 114 | Local Anesthetic Agents (Amides [Articaine]) | p. 118 OBJ: 2|3 TOP: NBDHE, 6.0. Pharmacology 14. Which nerve function is the most sensitive to inhibition by local anesthetic agents? a. Touch b. Warmth c. Pressure d. Autonomic e. Pain ANS: D

Sensitivity to inhibition by local anesthetics is a function of nerve diameter and myelination.

Postganglionic autonomic nerves are of small diameter and unmyelinated. The correct order of sensitivity is autonomic, warmth, pain, touch, and pressure.

DIF: Comprehension REF: Pharmacologic Effects (Peripheral Nerve Conduction (Blocker) [Box 10.3: Common Order of Nerve Function Loss]) | p. 114 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 15. The maximum safe dose of articaine 4% with 1:100,000 epinephrine is approximately

cartridges. a. 5.5 b. 6.9 c. 8.5 d. 11.5 ANS: B

The maximum safe dose of articaine 4% with 1:100,000 epinephrine or 1:200,000 epinephrine is 6.9 cartridges. The maximum safe dose of lidocaine 2% with 1:100,000 epinephrine or 1:200,000 epinephrine is approximately 8.5 cartridges. For lidocaine 2% with 1:50,000 epinephrine, the maximum is approximately 5.5 cartridges. 11.5 cartridges is not correct for any of the local anesthetics currently available.

DIF: Recall REF: Adverse Reactions (Table 10.3: Maximum Safe Dose (MSD) of Local Anesthetics) | p. 115 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 16. Which of the following agents are the most likely to precipitate malignant hyperthermia: (1) halothane,

(2) lidocaine, (3) mepivacaine, (4) succinylcholine? a. 1, 2, 3, 4 b. 2, 3, 4 c. 2, 3 d. 1, 4 ANS: D

Halothane, the inhalation anesthetic, and succinylcholine, the neuromuscular blocking agent, are the most common agents precipitating malignant hyperthermia. In the past, the belief was that the amide local anesthetics might precipitate malignant hyperthermia, but they are currently no longer implicated.

Patients with a family history of malignant hyperthermia can be given amide local anesthetic agents.

DIF: Comprehension REF: Adverse Reactions (Malignant Hyperthermia) | p. 115 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

17. Which of the following local anesthetics is safest to use for dental treatment for a pregnant woman? a. Mepivacaine b. Lidocaine c. Articaine d. Bupivacaine ANS: B

If a local anesthetic is needed, lidocaine in the smallest effective dose should be used. Both lidocaine and prilocaine are acceptable choices. Incorrect choices: Mepivacaine, articaine, and bupivacaine are not the best choice if local anesthetic is to be administered to a pregnant woman.

DIF: Recall OBJ: 2

REF: Adverse Reactions (Pregnancy and Nursing Considerations) | p. 115 TOP: NBDHE, 6.0. Pharmacology

18. Which of the following components of an injected amide local anesthetic agent may produce a

hypersensitivity reaction that exhibits itself as an acute asthmatic attack? a. The vasoconstrictor b. The antioxidant for the vasoconstrictor c. The sodium hydroxide d. The sodium chloride ANS: B

Amide local anesthetics with vasoconstrictors also contain a sulfite that serves as an antioxidant preservative. In sulfite-sensitive patients, the sulfites may produce a hypersensitivity reaction that exhibits itself as an acute asthmatic attack. This reaction is the same as the “salad bar” syndrome, a hypersensitivity reaction to sulfites. The remaining choices are not the components of an amide local anesthetic cartridge that are associated with triggering an allergic reaction.

DIF: Comprehension REF: Adverse Reactions (Allergy) | p. 115 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 19. Epinephrine is combined with local anesthetics so as to a. enhance absorption. b. prolong duration of action. c. delay onset. d. increase potency.

ANS: B

Epinephrine restricts the diffusion of the local anesthetic away from the site of injection which allows the local anesthetic to stay at the site longer, producing a longer duration of action. Epinephrine does not enhance absorption, delay onset, or increase the potency of the local anesthetic agent with which it is combined.

DIF: Recall OBJ: 3

REF: Composition of Local Anesthetic Solutions | p. 116 TOP: NBDHE, 6.0. Pharmacology

20. The correct ADA color code for articaine 4% with epinephrine 1:100,000 is a. black. b. green. c. red. d. gold. e. brown.

ANS: D

The color code for articaine 4% with epinephrine 1:100,000 is gold. Prilocaine 4% plain is black, lidocaine 2% with epinephrine 1:50,000 is green, lidocaine 2% with epinephrine 1:100,000 is red, and mepivacaine 2% with levonordefrin 1:20,000 is brown.

DIF: Recall REF: Local Anesthetic Agents (Box 10.5: Local Anesthetic Cartridge Color Codes) | p. 116 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 21. Lidocaine 2% with epinephrine 1:100,000 provides a a. 30-minute b. 30- to 60-minute c. 60- to 90-minute d. 90-minute or more

duration of pulpal anesthesia.

ANS: C

Lidocaine 2% with epinephrine 1:100,000 provides a 1- to 1.5-hour duration of pulpal anesthesia. Softtissue anesthesia is maintained for 3 to 4 hours. Lidocaine with epinephrine 1:50,000 is used for hemostasis during surgical procedures. The remaining choices do not provide an accurate estimate of the duration of pulpal anesthesia one can expect when lidocaine with epinephrine 1:100,000 is used.

DIF: Application OBJ: 3

REF: Local Anesthetic Agents (Amides [Lidocaine]) | p. 117 TOP: NBDHE, 6.0. Pharmacology

22. Which of the following statements is true of mepivacaine? a. Cross-allergenicity has been demonstrated between mepivacaine and other

currently available amides. b. Mepivacaine is effective topically. c. Mepivacaine can be used as a 3% solution without a vasoconstrictor. d. The benefit of a shorter duration of anesthesia warrants eliminating the vasoconstrictor.

ANS: C

Because mepivacaine produces less vasodilation than lidocaine, it can be used as a 3% solution without a vasoconstrictor. It can be used for short procedures when a vasoconstrictor is contraindicated. Caution should be exercised when using the increased concentrations of the local anesthetic without a vasoconstrictor because systemic toxicity is more likely. No cross-allergenicity between the amide mepivacaine, other currently available amides, or the esters has been documented.

Mepivacaine is not effective topically; however, it is used for infiltration, block, spinal, epidural, and caudal anesthesia. Except in unusual cases, the benefit of a shorter duration does not warrant eliminating the vasoconstrictor, especially when the concentration of the drug is increased.

DIF: Comprehension REF: Local Anesthetic Agents (Amides [Mepivacaine]) | p. 117 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 23. Levonordefrin is commonly combined with which local anesthetic? a. Lidocaine b. Procaine c. Mepivacaine d. Bupivacaine ANS: C

Mepivacaine is the only local anesthetic listed that is available in combination with levonordefrin.

Lidocaine and bupivacaine are available with epinephrine, not levonordefrin. Procaine is an ester local anesthetic that is not used in dentistry today.

DIF: Comprehension REF: Local Anesthetic Agents (Amides [Mepivacaine]) | p. 117 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 24. Several cases of methemoglobinemia have been reported after the use of a. lidocaine. b. mepivacaine. c. prilocaine. d. articaine.

ANS: C

Although the toxicity of prilocaine is 60% of that occurring with lidocaine, several cases of methemoglobinemia have been reported after its use. Prilocaine is metabolized to orthotoluidine and, in large doses, can induce some methemoglobinemia. Although the small doses required in dental practice are not likely to present a problem in healthy, nonpregnant adults, prilocaine should not be administered to patients with any condition in which problems of oxygenation may be especially critical. Methemoglobinemia is a rare hereditary condition in which there is an inability of the blood to bind to oxygen. It is not associated with the remaining choices of dental local anesthetic.

DIF: Recall OBJ: 3

REF: Local Anesthetic Agents (Amides [Prilocaine]) | p. 117 TOP: NBDHE, 6.0. Pharmacology

25. Prilocaine plain has a duration of action slightly _

epinephrine has a duration of action slightly a. shorter; shorter b. shorter; longer c. longer; shorter d. longer; longer

than mepivacaine plain, and prilocaine with _ than lidocaine with epinephrine.

ANS: D

Prilocaine plain has a duration of action slightly longer than mepivacaine plain, and prilocaine with epinephrine has a duration of action slightly longer than lidocaine with epinephrine. Prilocaine’s niche in dentistry involves situations in which the desired duration of action is somewhat longer than that obtained with mepivacaine either with or without a vasoconstrictor. The other choices do not correctly describe the duration of action of prilocaine.

DIF: Recall OBJ: 3

REF: Local Anesthetic Agents (Amides [Prilocaine]) | p. 117 TOP: NBDHE, 6.0. Pharmacology

26. Which of the following local anesthetics has the longest duration of action? a. Lidocaine b. Mepivacaine c. Prilocaine d. Bupivacaine ANS: D

The major advantage of bupivacaine is its greatly prolonged duration of action. It is indicated in lengthy dental procedures when pulpal anesthesia of greater than 1.5 hours is needed or when postoperative pain is expected. It is used most frequently in the offices of oral surgeons and endodontists. Compared with lidocaine with epinephrine, the onset of bupivacaine with epinephrine is slightly longer, but the duration is at least twice that of lidocaine. The remaining local anesthetics do not have the longest duration of action.

DIF: Comprehension REF: Local Anesthetic Agents (Amides [Bupivacaine]) | p. 118 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27. Which local anesthetic agent is derived from thiophene? a. Tetracaine b. Bupivacaine c. Articaine d. Propoxycaine ANS: C

Articaine is unique from the other amide and ester local anesthetics in that it is derived from thiophene.

This allows for greater lipid solubility and ability to cross lipid barriers such as nerve membranes.

Tetracaine and propoxycaine are esters of PABA. Bupivacaine is an amide of xylidine.

DIF: Recall OBJ: 3

REF: Local Anesthetic Agents (Amides [Articaine]) | p. 118 TOP: NBDHE, 6.0. Pharmacology

28. Which of the following local anesthetic agents is both an ester and an amide? a. Benzonatate b. Articaine c. Bupivacaine d. Dyclonine ANS: B

Articaine differs from other amide local anesthetics because it also has an ester linkage. This causes articaine to be hydrolyzed by plasma esterase. Benzonatate is an ester, bupivacaine is an amide, and dyclonine is neither an ester nor an amide.

DIF: Application OBJ: 3

REF: Local Anesthetic Agents (Amides [Articaine]) | p. 118 TOP: NBDHE, 6.0. Pharmacology

29. Approximately a. 5 to 10 b. 20 to 25 c. 50 to 75 d. 90

% of articaine is metabolized by the liver.

ANS: A

The liver metabolizes only 5% to 10% of articaine; the other 90% to 95% is metabolized in the blood.

Its major metabolite is articainic acid, and the extent of activity of this metabolite is unclear. The other choices do not reflect the percentage of articaine that is metabolized by the liver. The ester linkage that occurs in articaine causes it to be hydrolyzed by plasma esterase, which reduces the amount metabolized in the liver.

DIF: Recall OBJ: 3

REF: Local Anesthetic Agents (Amides [Articaine]) | p. 118 TOP: NBDHE, 6.0. Pharmacology

30. Which of the following dental local anesthetics is associated with an increased incidence of paresthesia

following an inferior alveolar (IA) block? a. Lidocaine 2% with epinephrine 1:100,000 b. Lidocaine 2% with epinephrine 1:50,000 c. Mepivacaine 2% with levonordefrin 1:20,000 d. Prilocaine 4% with epinephrine 1:200,000 e. Articaine 4% with epinephrine 1:100,000 ANS: E

Paresthesia is a persistent anesthesia beyond the expected duration of the local anesthetic. Since being introduced in 2000 there have been many reports of paresthesia after the IA block when the 4% solution of articaine is used. The other dental local anesthetics have not been associated with an increased chance of paresthesia when used for an inferior alveolar block.

DIF: Recall OBJ: 3 31. a. b. c. d.

REF: Local Anesthetic Agents (Amides [Articaine]) | p. 118 TOP: NBDHE, 6.0. Pharmacology

is an ester local anesthetic.

Prilocaine (Citanest) Tetracaine (Pontocaine) Bupivacaine (Marcaine) Lidocaine (Xylocaine)

ANS: B

The chemical structure of tetracaine contains an ester linkage. It is not available in a dental cartridge.

Tetracaine is available in various sprays, solutions, and ointments for topical application. The other agents listed contain amide linkages.

DIF: Recall OBJ: 3

REF: Local Anesthetic Agents (Esters [Tetracaine]) | p. 118 TOP: NBDHE, 6.0. Pharmacology

32. Which local anesthetic agent is neither an ester nor an amide? a. Propoxycaine b. Dyclonine

c. Articaine d. Lidocaine ANS: B

Dyclonine is a topical local anesthetic that is neither an ester nor an amide. The solution and topical product are available in 0.5% and 1% concentrations. Propoxycaine is an ester local anesthetic, articaine has both amide and ester bonds, and lidocaine is an amide dental local anesthetic.

DIF: Comprehension REF: Local Anesthetic Agents (Other Local Anesthetics [Dyclonine]) | p. 118 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 33. Which of the following dental local anesthetic agents is available in a 1.7 ml dental cartridge unlike the

more common 1.8 ml dental cartridge? a. Lidocaine (Xylocaine, Octocaine) b. Bupivacaine (Marcaine) c. Mepivacaine (Carbocaine, Isocaine) d. Prilocaine (Citanest) e. Articaine (Septocaine) ANS: E

Articaine is available as a 4% concentration with 1:100,000 epinephrine in a 1.7 ml dental cartridge.

Articaine has been available in Europe since the mid-1970s. The other agents are available in a 1.8-ml dental cartridge.

DIF: Recall OBJ: 3

REF: Local Anesthetic Agents (Amides [Articaine]) | p. 118 TOP: NBDHE, 6.0. Pharmacology

34. The vasoconstrictors are members of the autonomic nervous system drugs called the a. adrenergic agonists. b. adrenergic antagonists. c. cholinergic agonists. d. cholinergic antagonists.

ANS: A

Vasoconstrictors are called adrenergic agonists or sympathomimetics. Cholinergic antagonists function most like adrenergic agonists; however, vasoconstrictors are not categorized as cholinergic antagonists. Vasoconstrictors do not belong to any of the other categories of neurotransmitters of the autonomic nervous system.

DIF: Comprehension REF: Vasoconstrictors (Overview) | p. 118 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 35. Plain anesthetics without vasoconstrictor will exhibit a

rapid buildup of a systemic blood level. a. shorter; less b. shorter; more c. longer; less d. longer; more

duration of action and result in a

ANS: B

Plain anesthetics will exhibit a shorter duration of action and result in a more rapid buildup of a systemic blood level. Therefore, any anesthetic given without a vasoconstrictor is more likely to be toxic than those given with a vasoconstrictor. Any advantage gained by eliminating the vasoconstrictor must be weighed against the potential for adverse effects from the epinephrine. The remaining “either/or” choices do not properly describe the duration of action of a plain anesthetic without vasoconstrictor.

DIF: Recall OBJ: 3

REF: Vasoconstrictors (Overview) | p. 119 TOP: NBDHE, 6.0. Pharmacology

36. Patients with uncontrolled high blood pressure, hyperthyroidism, angina pectoris, and cardiac

arrhythmias and those who have had a myocardial infarction or cerebrovascular accident in the past should make an appointment for elective dental treatment only after their medical condition is under control. a. 6 weeks b. 3 months c. 6 months d. 12 months ANS: C

Patients with any of the preceding conditions in the past 6 months should make an appointment for elective dental treatment after their medical condition is under control. For patients who have had a myocardial infarction or cerebrovascular accident, the time span would be 6 months after the cardiovascular or cerebrovascular event. The recommended time interval is very specific and the remaining choices are not correct.

DIF: Recall OBJ: 3

REF: Vasoconstrictors (Overview) | p. 119 TOP: NBDHE, 6.0. Pharmacology

37. The maximum safe dose of epinephrine for the cardiac patient is a. 0.02 b. 0.04 c. 0.2 d. 0.4

mg.

ANS: B

The maximum safe dose of epinephrine for the cardiac patient is 0.04 mg. This is about the amount in two cartridges of lidocaine with epinephrine 1:100,000. For the healthy patient, the maximum safe dose is 0.2 mg.

DIF: Recall OBJ: 3

REF: Vasoconstrictors (Overview) | p. 120 TOP: NBDHE, 6.0. Pharmacology

38. Which is the concentration of levonordefrin (Neo-Cobefrin) used in dentistry? a. 1:20,000 b. 1:50,000 c. 1:100,000 d. 1:200,000

ANS: A

Mepivacaine 2 percent contains levonordefrin 1:20,000. Lidocaine 2 percent is available with epinephrine 1:50,000 or 1:100,000. Articaine 4 percent is available with epinephrine 1:100,000 or 1:200,000. Prilocaine 4 percent is available with epinephrine 1:200,000.

DIF: Recall REF: Vasoconstrictors (Overview [Table 10.5: Vasoconstrictors: Maximum Safe Dose in Normal and Cardiac Patients]) | p. 120 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 39. A cardiac patient can be given

cartridges of a dental anesthetic with epinephrine 1:100,000 without exceeding the cardiac dose for the vasoconstrictor. a. 0.5 b. 2 c. 4 d. 6 ANS: B

A cardiac patient can be given 2 cartridges of a dental anesthetic with epinephrine 1:100,000 without exceeding the cardiac dose. The anesthetic should be administered in the lowest possible dose by means of the best technique, including aspiration and a very slow injection rate to minimize systemic absorption. A healthy person can tolerate about 11 cartridges with epinephrine 1:100,000, but the amount a cardiac patient can tolerate is far less.

DIF: Recall REF: Vasoconstrictors (Overview) | p. 118 | Vasoconstrictors (Overview [Table 10.5: Vasoconstrictors: Maximum Safe Dose in Normal and Cardiac Patients]) | p. 120 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 40. Which two agents are known to cause clinically significant drug interactions when combined with

epinephrine? a. Selective serotonin reuptake inhibitors and nonselective -blockers b. Nonselective -blockers and phenothiazines c. Tricyclic antidepressants and monoamine oxidase inhibitors d. Nonselective -blockers and tricyclic antidepressants e. Benzodiazepines and monoamine oxidase inhibitors ANS: D

Nonselective -blockers may cause hypertension followed by reflex bradycardia when combined with epinephrine, and tricyclic antidepressants may cause an exaggerated increase in pressor response.

Monoamine oxidase inhibitors and phenothiazines can interact with epinephrine, but the results are usually not clinically significant. Benzodiazepines do not significantly interact with epinephrine.

DIF: Comprehension REF: Vasoconstrictors (Drug Interactions) | p. 120 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 41. Which of the following agents is the most common topical local anesthetic? a. Lidocaine b. Benzocaine c. Tetracaine

d. Dyclonine ANS: B

Benzocaine, an ester, is the most commonly used topical local anesthetic. Lidocaine, an amide, is the second most commonly used topical local anesthetic. Tetracaine is an ester of para-aminobenzoic acid (PABA) and has a slow onset and long duration. In view of this drug’s high toxicity and the rapidity with which it is absorbed from mucosal surfaces, great care must be exercised if it is used for topical anesthesia. Dyclonine is a topical local anesthetic that is neither an ester nor an amide.

DIF: Recall REF: Topical Anesthetics | p. 121 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

42. Which of the following local anesthetics may be combined for injection-free local anesthesia? a. Articaine and bupivacaine b. Lidocaine and prilocaine c. Benzocaine and tetracaine d. Lidocaine and articaine ANS: B

The combination of lidocaine and prilocaine gel (Oraqix) applied into the periodontal pocket offers pain relief during scaling and root planning procedures. This combination, in gel form, provides a duration of action of approximately 20 minutes. The onset of action is approximately 30 seconds after application. This product is applied with a unique applicator. It is a liquid in the proprietary cartridge and becomes more viscous when applied. It is not indicated for patients who are hypersensitive to local anesthetics. It should not be used with patients who have congenital or idiopathic methemoglobinemia.

DIF: Recall REF: Topical Anesthetics (Amides [Lidocaine and Prilocaine (Injection-Free Local Anesthesia)]) | p. 122 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 43. Each of the following will decrease the ability of dental local anesthetic to penetrate the nerve fiber

except one. Which is the exception? a. Local inflammation b. Dilution by fluid c. Infection d. Free-base form ANS: D

The free-base form of local anesthetic is fat soluble and penetrates nerve tissue. Local inflammation causes a decrease in the pH of the tissue extracellular fluid and drives more of the local anesthetic into the ionized form, which is less able to penetrate the nerve. Edema or fluid in tissue dilutes the local anesthetic, which disperses in a 360 degree pattern from the location of the injection. Infection lowers the pH causing the local anesthetic to be associated with a hydrogen ion and making it hydrophilic rather than lipophilic.

DIF: Application OBJ: 2

REF: Mechanism of Action (Ionization Factors) | p. 112 TOP: NBDHE, 6.0. Pharmacology

44. Which dental local anesthetic is an ester? a. Lidocaine

b. c. d. e.

Mepivacaine Prilocaine Bupivacaine Benzocaine

ANS: E

Benzocaine, which is used topically but not by injection. Lidocaine, mepivacaine, prilocaine, and bupivacaine are all members of the amide group of local anesthetics. Currently, there are no esters available in a dental cartridge. Novocaine was an ester local anesthetic, but it is no longer available.

DIF: Comprehension REF: Local Anesthetic Agents (Esters) | p. 118 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 45. Cross-hypersensitivity has been found between lidocaine and which other dental local anesthetic? a. Mepivacaine b. Prilocaine c. Bupivacaine d. Articaine e. None of the above ANS: E

No cross-allergenicity between lidocaine and any other available amides or esters has been documented. None of the available local anesthetics have been shown to have cross-allergenicity with lidocaine.

DIF: Comprehension REF: Local Anesthetic Agents (Amides [Lidocaine]) | p. 116 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

46. Which percentage of local anesthetic in a dental cartridge has the longest duration of action? a. 0.5% b. 2% c. 3% d. 4% ANS: A

It has been used for infiltration, block, and peridural anesthesia. Bupivacaine (Marcaine) 0.5% with 1:200,000 epinephrine is the longest lasting local anesthetic used in dentistry.

DIF: Application OBJ: 3

REF: Local Anesthetic Agents (Amides [Bupivacaine]) | p. 118 TOP: NBDHE, 6.0. Pharmacology

47. The recommended concentration of epinephrine to combine with lidocaine is

needed. a. 1:20,000 b. 1:50,000 c. 1:100,000 d. 1:200,000 ANS: B

when hemostasis is

Lidocaine is available in either a 1:50,000 or 1:100,000 dose of epinephrine. In dentistry, lidocaine 2% with 1:100,000 epinephrine is used for infiltration and block anesthesia. A 1:50,000 dose is used in situations for which local hemostasis is needed. Lidocaine 2% is not available with either 1:20,000 or 1:200,000 epinephrine. Generally, the 1:100,000 concentration of epinephrine is used, 1:50,000 is recommended only when hemostasis is needed.

DIF: Recall REF: Local Anesthetic Agents (Amides [Lidocaine]) | p. 117 | Vasoconstrictors (Overview) | p. 119 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 48. No justification exists for the use of epinephrine in a concentration greater than

, except in

cases in which hemostasis is needed. a. 1:200,000 b. 1:100,000 c. 1:50,000 d. 1:20,000 ANS: A

A sufficient concentration must be used to keep the local anesthetic localized at its site of action and provide adequate depth and duration of anesthesia and low systemic toxicity. It has been shown that 1:100,000 and 1:200,000 produce about the same amount of vasoconstriction and the same distribution of the local anesthetics.

DIF: Recall OBJ: 3

REF: Vasoconstrictors (Overview) | p. 119 TOP: NBDHE, 6.0. Pharmacology

49. Dental local anesthetics containing vasoconstrictors should not be used in patients with cardiovascular

disease. The vasoconstrictor will elevate the blood pressure too much. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false. d. The first statement is false, the second statement is true.

ANS: B

A patient can produce endogenous epinephrine far in excess of that administered in dentistry in the presence of inadequate anesthesia. This sometimes occurs when vasoconstrictors are avoided. Medical consults often recommend that epinephrine be avoided because physicians are more familiar with the dose used in medicine. This was thought to be true in the 1940s, however, cardiac patients have shown they can safely tolerate the cardiac dose of epinephrine, which is 0.04 mg.

DIF: Comprehension REF: Vasoconstrictors (Overview) | p. 119 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 50. Which local anesthetic will have the shortest duration of action? a. Lidocaine (plain) without vasoconstrictor b. Lidocaine with vasoconstrictor c. Mepivacaine with vasoconstrictor d. Prilocaine with vasoconstrictor ANS: A

Lidocaine plain. Adding a vasoconstrictor increases the duration of action of any local anesthetic.

DIF: Comprehension REF: Choice of Local Anesthetic (Box 10.7: Categories of Duration of Action of Local Anesthetic AgentsPlain (Without) and With a Vasoconstrictor) | p. 121 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Which of the following dental local anesthetics are available without vasoconstrictor? (Select all that

apply.) a. Mepivacaine b. Prilocaine c. Articaine d. Bupivacaine ANS: A, B

Because mepivacaine (0.8) and prilocaine (0.5) have less vasodilating effect than lidocaine (1), they can be used without vasoconstrictor. Articaine and bupivacaine (2.5) produce too much vasodilation to be used without a vasoconstrictor.

DIF: Recall OBJ: 3

REF: Choice of Local Anesthetic | p. 121 TOP: NBDHE, 6.0. Pharmacology

TRUE/FALSE 1. The rate of local anesthetic absorption is increased by the presence of local inflammation.

ANS: F

Local inflammation causes a decrease in the pH of the tissue extracellular fluid and drives more of the local anesthetic into the ionized form, which is less able to penetrate nerves.

DIF: Recall OBJ: 2

REF: Mechanism of Action (Ionization Factors) | p. 112 TOP: NBDHE, 6.0. Pharmacology

2. Benzocaine cannot be converted to a water-soluble form for injection.

ANS: T

Because it is poorly soluble, it is poorly absorbed and lacks significant systemic toxicity.

DIF: Recall OBJ: 4

REF: Topical Anesthetics (Esters [Benzocaine]) | p. 123 TOP: NBDHE, 6.0. Pharmacology

3. Patients who are allergic to procaine are not likely to display cross-hypersensitivity to lidocaine.

ANS: T

Procaine is an ester of para-aminobenzoic acid (PABA). Ester local anesthetics have a much greater allergic potential than amides. Lidocaine is an amide. Allergy to lidocaine is unlikely, and crosshypersensitivity with procaine is even less likely because of the different chemical structures.

DIF: Recall REF: Local Anesthetic Agents (Amides [Lidocaine]) | p. 116 | Local Anesthetic Agents (Esters [Procaine]) | p.

118 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 4. For lengthy dental procedures, bupivacaine is recommended over lidocaine because bupivacaine has a

longer duration of action.

ANS: T

Bupivacaine is the longest lasting local anesthetic used in dentistry.

DIF: Recall OBJ: 3

REF: Local Anesthetic Agents (Amides [Bupivacaine]) | p. 118 TOP: NBDHE, 6.0. Pharmacology

5. The recommended concentration of epinephrine to combine with a local anesthetic is 1:200,000 for

most procedures.

ANS: T

Epinephrine 1:100,000 and 1:200,000 have been shown to produce about the same amount of vasoconstriction. A 1:50,000 dose is used in cases in which local hemostasis is needed.

DIF: Recall OBJ: 3

REF: Vasoconstrictors (Overview) | p. 119 TOP: NBDHE, 6.0. Pharmacology

6. No justification exists for the use of epinephrine in a concentration greater than 1:200,000, except in

cases in which hemostasis is needed.

ANS: T

It has been shown that 1:100,000 and 1:200,000 produce about the same amount of vasoconstriction and the same distribution of the local anesthetics.

DIF: Recall OBJ: 3

REF: Vasoconstrictors (Overview) | p. 119 TOP: NBDHE, 6.0. Pharmacology

7. A patient can produce endogenous epinephrine far in excess of that administered in dentistry in the

presence of inadequate anesthesia.

ANS: T

This sometimes occurs when vasoconstrictors are avoided. Medical consults often recommend that epinephrine be avoided because physicians are more familiar with the dose used in medicine.

DIF: Recall OBJ: 3

REF: Vasoconstrictors (Overview) | p. 119 TOP: NBDHE, 6.0. Pharmacology

8. Levonordefrin is more potent than epinephrine.

ANS: F

Levonordefrin has one-fifth the pressor potency of epinephrine.

DIF: Recall

REF: Vasoconstrictors (Overview [Table 10.5: Vasoconstrictors: Maximum Safe Dose in Normal and Cardiac Patients]) | p. 120 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

Chapter 11: Antianxiety Agents Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which of the following dental specialists is most likely to use general anesthetic drugs in their offices? a. Prosthodontist b. Endodontist c. Oral and maxillofacial surgeon d. Orthodontist e. Pediatric dentist ANS: C

Oral and maxillofacial surgeons are the most likely to use general anesthetic drugs in their offices.

General dentists are more likely to use nitrous oxide to provide conscious sedation and pain control.

The other choices do not represent the dental specialist most likely to use general anesthesia in a dental office.

DIF: Recall REF: Introduction | p. 125 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. Which of the following general anesthetic agents was introduced in the middle 1800s and led to a

dramatic reduction in surgically related mortality? a. Propofol b. Isoflurane c. Ether d. Nitrous oxide ANS: C

In 1846, surgically related mortality dropped dramatically with the introduction of ether. Ether is not used today because modern operating rooms have a lot of electrical equipment and ether is highly explosive. Propofol is a recent addition to the general anesthetic armamentarium. Isoflurane was not introduced in the middle 1800s. Nitrous oxide was discovered in 1776, but it is not used as a general anesthetic.

DIF: Recall REF: History | p. 125 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. According to Guedel’s description of the stages and planes of anesthesia, the induction period refers to

stage a. I. b. II. c. I and II. d. I, II, and III. e. None of the above is correct.

ANS: C

The term induction refers to all the preparation and medication necessary for a patient up to the time the operation begins. This includes all preoperative medication, adjunctive drugs to anesthesia, and anesthetics required for induction. Induction includes both stage I and stage II but not stage III, the point at which surgical anesthesia is attained.

DIF: Application OBJ: 2

REF: Mechanism of Action (Stages and Planes of Anesthesia) | p. 125 TOP: NBDHE, 6.0. Pharmacology

4. Nitrous oxide, as used in the dental office, maintains the patient in stage

of Guedel’s system of

stages and planes. a. I b. II c. III d. IV ANS: A

Nitrous oxide maintains the patient in stage I. Stage I analgesia is characterized by the development of analgesia or reduced sensation to pain. The patient is conscious and can still respond to commands.

Reflexes are present, and respiration remains regular. Some amnesia may also be present. Stage II begins with unconsciousness and is associated with involuntary movement and excitement. Stage III is the stage in which most major surgery is performed. Stage IV is characterized by cessation of all respiration.

DIF: Comprehension REF: Mechanism of Action (Stages and Planes of Anesthesia) | p. 125 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 5. The loss of respiratory control (i.e., diminished carbon dioxide response, paralysis of intercostal

muscles) first occurs during which of Guedel’s stages of anesthesia? a. Stage I b. Stage II c. Stage III d. Stage IV ANS: C

Paralysis of intercostal muscles begins in plane III and is complete in plane IV of stage III anesthesia.

The other choices do not represent the correct Stage of anesthesia as described by Guedel in 1920.

Respiration remains regular in Stage I. Respiration becomes irregular in Stage II. DIF: Application OBJ: 2

REF: Mechanism of Action (Stages and Planes of Anesthesia) | p. 126 TOP: NBDHE, 6.0. Pharmacology

6. Which of the following intravenous general anesthetic agents can be administered intramuscularly

(IM)? a. Methohexital (Brevital) b. Ketamine (Ketalar) c. Diazepam (Valium) d. Propofol (Diprivan) ANS: B

Although most injectable general anesthetics are administered intravenously (IV), one agent, ketamine, can also be given intramuscularly (IM). Methohexital is an ultrashort-acting barbiturate that is administered intravenously. Diazepam is a benzodiazepine that has been used intravenously for many years. Propofol is an IV anesthetic.

DIF: Recall REF: General Anesthetics (Induction Anesthesia [Intravenous Anesthetics]) | p. 126 | General Anesthetics (Induction Anesthesia [Ketamine]) | p. 127 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 7. Recovery from a single intravenous dose of methohexital (Brevital) is accelerated as a result of a. b. c. d.

to lean tissues. drug excretion drug redistribution drug metabolism enzyme induction

ANS: B

Brevital is an ultrashort-acting barbiturate. These drugs are highly lipid soluble and repeated dosing during anesthesia can result in a prolonged recovery period. However, blood and brain levels quickly decrease as the drugs redistribute to lean tissues. Drug excretion and metabolism occur with methohexital sodium (Brevital), but they are preceded by drug redistribution. Enzyme induction is a long-term action of barbiturates and is not responsible for termination of a single dose of Brevital.

DIF: Comprehension REF: General Anesthetics (Induction Anesthesia [Ultrashort-Acting Barbiturates]) | pp. 126-127 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 8. The following are characteristics of propofol except which one? a. Rapid onset of action b. Produces little vomiting c. Undergoes phase II metabolism in the liver d. Intravenous anesthetic e. Structurally related to barbiturates ANS: E

Propofol is an agent that is unrelated to any other general anesthetic. Patients “feel better” and begin ambulation sooner than with other agents. It is popular for outpatient surgery. Propofol is ultrashort acting, produces little vomiting and may have antiemetic effects, metabolized in the liver, and administered intravenously.

DIF: Application OBJ: 3

REF: General Anesthetics (Induction Anesthesia [Propofol]) | p. 127 TOP: NBDHE, 6.0. Pharmacology

9. Which of the following effects is not a characteristic of the action of ketamine? a. Produces “dissociative” anesthesia b. Causes xerostomia c. Increases cardiac output d. Causes recovery associated with delirium and hallucinations

ANS: B

Ketamine does not cause xerostomia. Atropine is a necessary premedication because excessive salivation is a common finding with ketamine. An advantage of ketamine is that it may be administered intravenously or intramuscularly. Ketamine does produce a dissociative anesthesia, increases cardiac output, and can cause delirium and hallucinations. Ketamine is primarily used by oral surgeons. It is not used in general dentistry.

DIF: Comprehension REF: General Anesthetics (Induction Anesthesia [Ketamine]) | p. 127 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 10. Which of the following is the major disadvantage of the use of opioids as an adjunctive drug to general

anesthesia in preanesthetic medication? a. Hypertensive crisis b. Respiratory depression c. Hallucinations d. Salivary stimulation ANS: B

Prolonged respiratory depression is the major disadvantage and requires careful attention to ventilatory function throughout the anesthetic period. The remaining choices are not associated with the use of opioids during general anesthesia.

DIF: Comprehension REF: General Anesthetics (Induction Anesthesia [Opioids]) | p. 127 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 11. Nitrous oxide has a. rapid; high b. rapid; low c. slow; high d. slow; low

onset and

solubility in blood.

ANS: B

Nitrous oxide has low solubility (0.47), which correlates well with its rapid onset and recovery. It is the least soluble in blood of all inhalation anesthetics. It has little potency and is used in clinical outpatient dentistry as an inhaled agent that results in conscious sedation. High solubility in blood often retards onset of action. Halothane has a higher solubility (2.30) than nitrous oxide and has a longer induction and recovery and changes in level of anesthesia occur more slowly.

DIF: Application REF: General Anesthetics (Induction and Maintenance Anesthesia [Physical Factors]) | p. 128 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 12. Nitrous oxide combined with oxygen (N2O/O2) has become a primary part of dental office

procedures. a. anxiety reduction b. general anesthesia c. sleep apnea d. bruxism

ANS: A

Nitrous oxide is used for anxiety reduction. It provides anxiety relief coupled with analgesia. When nitrous oxide is properly administered, the patient remains conscious with protective reflexes intact.

Nitrous oxide is not used to relieve sleep apnea or bruxism.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide) | p. 128 TOP: NBDHE, 6.0. Pharmacology

13. The average percentage of nitrous oxide required for patient comfort is a. 10%. b. 25%. c. 35%. d. 50%.

ANS: C

The average percentage of nitrous oxide required for patient comfort is 35%. The percentage of nitrous oxide required for comfort is variable and may range from 10% to 50%. The other choices do not represent the average percentage of nitrous oxide needed for patient comfort. Fifty percent nitrous oxide is the maximum that can be delivered by modern nitrous oxide machines.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide) | p. 128 TOP: NBDHE, 6.0. Pharmacology

14. At the termination of a N2O/O2 sedation procedure, the patient should be placed on 100% oxygen for

at least a. 2 b. 5 c. 8 d. 11

minutes.

ANS: B

At the termination of a N2O/O2 sedation procedure, the patient should be placed on 100% oxygen for at least 5 minutes. If the mask is removed without the oxygen recovery period and the patient is allowed to breathe room air, a phenomenon known as diffusion hypoxia may result. It is very important to place the patient on 100% oxygen for a sufficient amount of time at the end of the procedure in order to avoid diffusion hypoxia.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide) | p. 129 TOP: NBDHE, 6.0. Pharmacology

15. Diffusion hypoxia may occur if insufficient 100% oxygen is delivered at the termination of a nitrous

oxide procedure because a. the lungs are insufficiently inflated. b. the loss of carbon dioxide could decrease ventilation. c. nitrous oxide is highly soluble in blood. d. nitrous oxide has a slow onset and recovery.

ANS: B

Diffusion hypoxia occurs because of the rapid outward flow of nitrous oxide accompanied by oxygen and carbon dioxide. The loss of carbon dioxide, a stimulant to the respiratory drive, could decrease ventilation with resultant hypoxia. The patient may complain of headaches or other side effects if this occurs. Nitrous oxide does not cause deflation of the lungs. Nitrous oxide is very insoluble in blood, which leads to quick onset and recovery.

DIF: Comprehension REF: General Anesthetics (Nitrous Oxide) | p. 129 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 16. The best indicator of the degree of sedation under nitrous oxide is a. response to a painful stimulus. b. percent nitrous oxide being delivered. c. response to questions. d. muscle tone. e. eye movements.

ANS: C

The best indicator of the degree of sedation is the patient’s response to questions. Perform repeated evaluations throughout the dental procedure. Response to a painful stimulus should only be evaluated after one is confident that adequate sedation has been achieved. The percentage of nitrous oxide is a poor indicator of degree of sedation. Muscular relaxation in response to nitrous oxide cannot be demonstrated in most patients. Eye movements are not predictive of adequate sedation by nitrous oxide.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide) | p. 129 TOP: NBDHE, 6.0. Pharmacology

17. The correct method for administration of nitrous oxide is to put the patient on a. 100% oxygen for 2 to 3 minutes and then put the nitrous oxide level at 20% of the b. c. d. e.

level of oxygen.

100% oxygen for 2 to 3 minutes and then put the nitrous oxide level at 50% of the level of oxygen.

100% oxygen for 2 to 3 minutes and add nitrous oxide in 5 to 10% increments until sedation is achieved.

50% oxygen and 50% nitrous oxide.

75% oxygen and 25% nitrous oxide.

ANS: C

The patient should be put on 100% oxygen for 2 to 3 minutes to determine the tidal volume. The nitrous oxide should be titrated until the patient response indicates an effect. The percentage required to achieve sedation may be different from one day to the next for the same patient. Titration of nitrous oxide is the key principle, meaning that the percentage of nitrous oxide is incrementally adjusted for that patient on that day until the desired effect is achieved.

DIF: Comprehension REF: General Anesthetics (Nitrous Oxide) | p. 128 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 18. Nitrous oxide cylinders are

orange, and (5) tan.

and oxygen cylinders are

: (1) red, (2) green, (3) blue, (4)

a. b. c. d. e.

1; 2 3; 2 2; 4 3; 4 3; 5

ANS: B

Nitrous oxide cylinders are blue, and oxygen cylinders are green. The cylinders are also “pin coded” to prevent inadvertent mixing of cylinders and lines. The remaining choices are not correct.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide [Adverse Reactions]) | p. 129 TOP: NBDHE, 6.0. Pharmacology

19. A patient for whom nitrous oxide is to be administered should be warned to avoid eating a large meal

within a. 2 b. 3 c. 4 d. 5

hours of the appointment.

ANS: B

The patient should eat a light meal before the appointment but should be warned to avoid eating a large meal within 3 hours of the appointment. A patient planning to receive nitrous oxide should be warned to avoid eating a large meal. The time frame is very specific.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide [Adverse Reactions]) | p. 129 TOP: NBDHE, 6.0. Pharmacology

20. Nitrous oxide has been shown to reduce the activity of methionine synthetase, the enzyme involved

with the function of which vitamin? a. Vitamin B1 b. Vitamin K c. Vitamin B6 d. Folic acid e. Vitamin B12 ANS: E

Chronic nitrous oxide abuse can produce a neuropathy that is thought to be caused by the inhibition of this enzyme and its effect on the utilization of vitamin B12. The remaining choices are not involved with methionine synthetase.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide [Adverse Reactions]) | p. 129 TOP: NBDHE, 6.0. Pharmacology

21. Nitrous oxide is contraindicated for use in a patient with which of the following conditions? a. Diabetes b. Emphysema c. Hypertension d. Glaucoma e. None of the above

ANS: B

Use of nitrous oxide is contraindicated in patients with any type of upper respiratory or pulmonary obstruction. Patients with chronic obstructive pulmonary disease (COPD), particularly emphysema, have respirations that are driven by a lack of oxygen and not by elevated carbon dioxide levels. These patients would have a great difficulty if they received more oxygen than they normally breathe.

Diabetes and glaucoma are not contraindications to nitrous oxide administration. Nitrous oxide causes vasodilation; thus it does not exacerbate hypertension.

DIF: Comprehension REF: General Anesthetics (Nitrous Oxide [Contraindications and Dental Issues]) | p. 129 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 22. Desflurane and sevoflurane have a low blood/gas partition coefficient. This means they have a more

rapid onset and shorter duration of action than the other halogenated hydrocarbon anesthetics. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: A

These are true, however, there are other difficulties. Desflurane’s low volatility requires a special vaporizer. Because it induces cough and laryngospasm, it cannot be used for induction. Recovery from anesthesia with desflurane, despite its physical properties, does not appear to be faster than with older agents. Sevoflurane is chemically unstable when exposed to carbon dioxide absorbents, producing a potentially nephrotoxic compound. Because it releases fluoride (F-) when metabolized, renal damage may occur.

DIF: Comprehension REF: General Anesthetics (Halogenated Hydrocarbons [Desflurane and Sevoflurane]) | p. 130 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 23. Which inhalational agent has a pungent smell and can cause respiratory acidosis with deeper levels of

anesthesia? a. Isoflurane b. Halothane c. Enflurane d. Sevoflurane e. Nitrous oxide ANS: A

Of the agents listed, only isoflurane is irritating and causes significant respiratory acidosis. Halothane, enflurane, sevoflurane, and nitrous oxide are not associated with respiratory acidosis or excessive irritation.

DIF: Recall OBJ: 5

REF: General Anesthetics (Halogenated Hydrocarbons [Isoflurane]) | p. 130 TOP: NBDHE, 6.0. Pharmacology

24. Which of the following types of agents is used during balanced general anesthesia to help the patient

pass from stage I to stage III and skip over the signs of stage II?

a. b. c. d.

Ketamine Propofol Ultrashort-acting IV barbiturate Opioids

ANS: C

The ultrashort IV barbiturates accomplish this readily. These barbiturates are combined with the N 2OO2 in combination, which are then administered with a volatile inhalation anesthetic. The remaining choices are not agents used to help the patient avoid signs of stage II. DIF: Recall OBJ: 6

REF: Balanced General Anesthesia | p. 130 TOP: NBDHE, 6.0. Pharmacology

25. The more soluble the anesthetic is in body tissues, the more rapid the onset and recovery will be. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: D

The less soluble the anesthetic is in body tissues, the more rapid the onset and recovery will be.

Nitrous oxide has a low solubility, so it is harder to push it into the lung tissue alveoli and it is rapidly cleared. This is very useful in clinical practice, because if the patient does not like the effect of nitrous oxide he or she can breathe through the mouth and quickly recover. A more soluble anesthetic will remain in the body longer. A less soluble anesthetic will be excreted more rapidly.

DIF: Comprehension REF: General Anesthetics (Induction and Maintenance Anesthesia [Physical Factors]) | p. 128 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 26. Features of nitrous oxide administration include each of the following except one. Which is the

exception? a. Nitrous oxide has low solubility in blood. b. Nitrous oxide alone is a good choice for a general anesthetic. c. Nitrous oxide has a quick onset. d. The patient will recover quickly following termination of administration of nitrous oxide.

ANS: B

Nitrous oxide cannot produce complete anesthesia alone. It may be used in combination with other anesthetics for general anesthesia. When nitrous oxide is administered properly, the patient remains conscious. Nitrous oxide has very low solubility in blood, which means the patient will recover quickly from the effects of administration of nitrous oxide.

DIF: Comprehension REF: Induction and Maintenance Anesthesia (Physical Factors [Table 11.4: Physical Properties of Selected Inhalation General Anesthetics]) | p. 128 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27. A patient should be given 100% oxygen for 5 minutes after treatment with nitrous oxide to prevent

a. b. c. d.

neuropathy. dissociative anesthesia. diffusion hypoxia. respiratory paralysis.

ANS: C

Diffusion hypoxia may result because of the rapid outward flow of nitrous oxide accompanied by oxygen and carbon dioxide. The loss of carbon dioxide, a stimulant to respiratory drive, could decrease ventilation with resultant hypoxia. Neuropathy may be a consequence of chronic nitrous oxide misuse.

Dissociative anesthesia is associated with the use of ketamine. Respiratory paralysis is associated with Guedel’s Stage IV of anesthesia.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide) | p. 129 TOP: NBDHE, 6.0. Pharmacology

28. Each of the following is true of patient instructions prior to the administration of nitrous oxide except

one. Which is the exception? a. The patient should eat a light meal before the appointment. b. The patient should avoid eating a large meal within 3 hours of the appointment. c. The patient must bring another person to transport them home as the patient should not drive himself or herself home alone following administration of nitrous oxide. d. Nitrous oxide is an excellent choice for a needle-phobic patient.

ANS: C

Nitrous oxide is the only anesthetic for conscious sedation available where the patient can drive home alone following the appointment. The patient should eat a light meal before the appointment but should be warned to avoid eating a large meal within 3 hours of the appointment. Often a patient with anxiety about the dental procedure also has anxiety about needles. Nitrous oxide is an excellent choice for these patients.

DIF: Application OBJ: 4

REF: General Anesthetics (Nitrous Oxide [Adverse Reactions]) | p. 129 TOP: NBDHE, 6.0. Pharmacology

29. A patient who has been administered nitrous oxide often will think the procedure is shorter than it was

due to which quality of nitrous oxide? a. Euphoria b. Anesthesia c. Analgesia d. Amnesia ANS: D

The amnestic qualities may help the patient assume that the procedure was much shorter than it actually was. Euphoria is a feeling of elation. Anesthesia is insensitivity to a painful stimulus.

Analgesia is a reduction in the level of pain.

DIF: Recall OBJ: 4 MULTIPLE RESPONSE

REF: General Anesthetics (Nitrous Oxide) | p. 129 TOP: NBDHE, 6.0. Pharmacology

1. Which of the following are types of intravenous general anesthetics? (Select all that apply.) a. Opioids b. Enflurane c. Etomidate d. Isoflurane e. Propofol ANS: A, C, E

The opioids have long been used as adjunctive drugs to general anesthesia in preanesthetic medication and to provide analgesia during and after a surgical procedure. Etomidate is a short-acting intravenous anesthetic agent used for the induction of general anesthesia and for sedation. Propofol is an intravenous anesthetic that produces an onset of anesthesia in 30 seconds. Enflurane is a halogenated ether anesthetic. Isoflurane is chemically related to enflurane.

DIF: Comprehension REF: General Anesthetics (Classification of Anesthetic Agents [Table 11.3: Classification of General Anesthetics by Route of Administration]) | p. 127 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following are true of etomidate? (Select all that apply.) a. It is a halogenated hydrocarbon for general anesthesia. b. It is used for induction of general anesthesia. c. It can cause adrenal suppression. d. It produces dissociative anesthesia.

ANS: B, C

Etomidate is a short-acting intravenous anesthetic agent used for induction of general anesthesia and for sedation. It has a rapid onset of action and a safe cardiovascular profile. It can cause adrenal suppression, especially after repeated dosing. It is an intravenous anesthetic. Ketamine produces dissociative anesthesia.

DIF: Comprehension REF: General Anesthetics (Induction Anesthesia [Etomidate]) | p. 127 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 3. Which of the following are benzodiazepines that are used for conscious sedation and preanesthetic

medication prior to general anesthesia? (Select all that apply.) a. Diazepam (Valium) b. Fentanyl (Sublimaze) c. Midazolam (Versed) d. Methohexital sodium (Brevital) ANS: A, C

Diazepam (Valium) has been used intravenously for many years. It is highly lipid soluble, has a quick onset, and is concentrated in adipose tissue. Midazolam (Versed) is water soluble and does not need a solvent for solution, so one of diazepam’s major side effects, thrombophlebitis, can be avoided by using midazolam. Fentanyl (Sublimaze) is an opioid. Methohexital sodium (Brevital) is an ultrashortacting barbiturate.

DIF: Comprehension REF: General Anesthetics (Induction Anesthesia [Benzodiazepines]) | pp. 127-128 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 4. Which of the following statements are true about volatile general anesthetics? (Select all that apply.) a. They are liquids that evaporate easily at room temperature. b. They are classified as halogenated hydrocarbons and ethers. c. They are known to have good solubility in body tissues. d. They are administered intravenously (IV).

ANS: A, B

Volatile general anesthetics are liquids with low boiling points. They are classified as halogenated hydrocarbons and halogenated ethers because they contain fluorine, chlorine, or bromine. Volatile general anesthetics have limited solubility in body tissues. They are administered as volatile liquids, not IV. DIF: Comprehension REF: General Anesthetics (Induction and Maintenance Anesthesia [Inhalation Anesthetics]) | p. 128 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 5. The less soluble the anesthetic is in body tissues, the more rapid the a. onset b. breathing rate c. heart rate d. recovery

. (Select all that apply.)

ANS: A, D

Less solubility will lead to rapid onset and recovery. An anesthetic drug with a higher solubility will have a longer induction and slower recovery. Changes in the level of anesthesia will occur more slowly. The heart rate and breathing rate are not correlated with anesthetic solubility.

DIF: Comprehension REF: General Anesthetics (Induction and Maintenance Anesthesia [Physical Factors]) | p. 128 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 6. What are the goals of surgical anesthesia? (Select all that apply.) a. Good patient control b. Adequate muscle relaxation c. Reduced respiratory rate d. Reduced cardiac output e. Pain relief ANS: A, B, E

The goals of surgical anesthesia are good patient control, adequate muscle relaxation, and pain relief.

There are many agents that can produce good general anesthesia. Each drug has its own adverse reaction profile. Reduced respiratory rate and cardiac output are not goals of general anesthesia.

DIF: Comprehension REF: Balanced General Anesthesia | p. 130 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology

TRUE/FALSE 1. The more soluble the anesthetic is in body tissues, the more rapid the onset and recovery will be.

ANS: F

The less soluble the anesthetic is in body tissues, the more rapid the onset and recovery will be.

DIF: Recall REF: General Anesthetics (Induction and Maintenance Anesthesia [Physical Factors]) | p. 128 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 2. Nitrous oxide is a complete anesthetic.

ANS: F

Nitrous oxide cannot produce complete anesthesia alone.

DIF: Recall REF: General Anesthetics (Induction and Maintenance Anesthesia [Physical Factors] [Table 11.4: Physical Properties of Selected Inhalation General Anesthetics]) | p. 128 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 3. To prevent diffusion hypoxia, patients should be given 100% oxygen for 5 minutes after treatment

with nitrous oxide.

ANS: T

Diffusion hypoxia may result because of the rapid outward flow of nitrous oxide accompanied by oxygen and carbon dioxide. The loss of carbon dioxide, a stimulant to respiratory drive, could decrease ventilation with resultant hypoxia.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide) | p. 129 TOP: NBDHE, 6.0. Pharmacology

4. Patients should be instructed to fast before a dental procedure using nitrous oxide.

ANS: F

The patient should eat a light meal before the appointment but should be warned to avoid eating a large meal within 3 hours of the appointment.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide [Adverse Reactions]) | p. 129 TOP: NBDHE, 6.0. Pharmacology

5. Nitrous oxide has amnestic qualities.

ANS: T

The amnestic qualities may help the patient assume that the procedure was much shorter than it actually was.

DIF: Recall OBJ: 4

REF: General Anesthetics (Nitrous Oxide) | p. 129 TOP: NBDHE, 6.0. Pharmacology

Chapter 12: Drugs for the Treatment of Cardiovascular Diseases

Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Each of the following conditions is an absolute contraindication to dental treatment until a consultation

with the patient’s medical provider has determined any special treatment alterations that might be warranted except one. Which is the exception? a. Chronic, stable angina b. Uncontrolled heart failure c. Uncontrolled arrhythmia d. Significant, uncontrolled hypertension ANS: A

Chronic, stable angina is not a contraindication to dental treatment. According to the most current ACC/AHA guidelines, the primary goals of therapy for a patient with chronic, stable angina are to prevent a myocardial infarct and death and to completely or nearly completely eliminate ischemic symptoms. Unstable or recent onset of angina pectoris, uncontrolled heart failure, uncontrolled arrhythmias, and significant, uncontrolled hypertension are all cardiovascular contraindications to dental treatment.

DIF: Comprehension REF: Dental Implications of Cardiovascular Disease (Contraindications to Treatment) | p. 133 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. MI refers to a. injury or necrosis of the heart muscle. b. transient lack of oxygen to the heart. c. congestive heart failure (CHF). d. abnormal sinus rhythm of the heart.

ANS: A

Myocardial infarction (MI) is an occlusion or blockage of arteries supplying the muscles of the heart, resulting in injury or necrosis of the heart muscle (heart attack). Transient lack of oxygen to the heart is myocardial ischemia. Myocardial infarction does not refer to CHF, which is a chronic condition, or abnormal sinus rhythm of the heart.

DIF: Application REF: Heart Failure | p. 145 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

3. How long should a person who has had a myocardial infarction wait before receiving dental care? a. 2 weeks b. 2 months c. 6 months d. 12 months e. 24 months ANS: C

Patients who have suffered a myocardial infarction should wait 6 months before receiving any type of oral health care in order to give the heart a chance to heal. Bacteria from the mouth can enter the bloodstream and weaken an already weakened heart. If oral health care is necessary prior to the 6month time period, one should consult with the patient’s cardiologist or general practitioner to determine whether or not the patient’s heart has healed sufficiently. The amount of time to wait prior to receiving dental care is specifically stated.

DIF: Recall REF: Dental Implications of Cardiovascular Disease (Contraindications to Treatment) | p. 133 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. Which of the following is true concerning what research has shown regarding the relationship between

periodontal disease and cardiovascular disease? a. Studies have shown a very strong positive correlation between periodontal disease and cardiovascular disease. b. Studies have shown a weak but positive correlation between periodontal disease and cardiovascular disease. c. Studies both support and reject the relationship between periodontal disease and cardiovascular disease. d. Studies have shown that there is no correlation between periodontal disease and cardiovascular disease.

ANS: C

Studies both support and reject the relationship between periodontal disease and cardiovascular disease. Researchers and government agencies continue to investigate the possible relationship between periodontal disease and cardiovascular disease. Researchers do agree that more studies are needed. Studies have been controversial, showing both a relationship and no relationship between periodontal disease and cardiovascular disease.

DIF: Comprehension REF: Dental Implications of Cardiovascular Disease (Periodontal Disease and Cardiovascular Disease) | p. 134 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Which of the following statements is true of heart failure? a. Usually the right side fails first. b. If the left side of the heart fails, the blood backs up into the pulmonary circulation. c. If the right side of the heart fails, then the left ventricle is unable to remove all the

blood from the right side of the heart. d. Left-sided heart failure causes systemic congestion.

ANS: B

If the left side of the heart fails, the blood backs up into the pulmonary circulation. Pulmonary edema results, producing dyspnea and orthopnea. The left side usually fails first. If the right side of the heart fails, then the right ventricle is unable to remove all the blood from the right side of the heart. Rightsided heart failure causes systemic congestion. Symptoms include peripheral edema, with fluid accumulation evidenced by pitting edema.

DIF: Comprehension REF: Heart Failure | p. 145 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

6. Dental patients with left heart failure may need to be positioned in the dental chair a. with their left hip elevated. b. with their right hip elevated. c. in a semireclined position. d. with their feet at a higher elevation than their head. e. lying flat.

ANS: C

Full-reclining position may precipitate dyspnea or orthopnea (breathing difficulty experienced while lying flat). Elevation of one hip is indicated for some pregnant women requiring dental treatment during their third trimester. Lying in a flat position or with feet elevated above the head could precipitate orthopnea.

DIF: Recall REF: Heart Failure | p. 145 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

7. Which of the following is the primary type of drug recommended for patients who have edema or fluid

retention with heart failure (HF)? a. Angiotensin-converting enzyme inhibitor b. Angiotensin receptor antagonist c. Beta-blocker d. Aldosterone antagonist e. Diuretic ANS: E

Most patients with HF have edema or fluid retention. Diuretics are used in these patients to relieve the symptoms of HF. The American College of Cardiology and the American Heart Association recommend that all patients who have evidence of fluid retention and for most patients with a history of fluid retention be prescribed a diuretic. Diuretics should be combined with angiotensin-converting enzyme inhibitors, beta-blockers, angiotensin receptor antagonists, or aldosterone antagonists.

DIF: Recall OBJ: 3

REF: Heart Failure (Treatment of Heart Failure [Diuretics]) | p. 146 TOP: NBDHE, 6.0. Pharmacology

8. Which of the following choices are effects of digoxin on the heart? a. Digoxin accelerates atrioventricular (AV) conduction. b. Digoxin prolongs the refractory period of the atrioventricular (AV) node. c. Digoxin increases the rate of the sinoatrial (SA) node. d. Both A and B are effects. e. Both B and C are effects.

ANS: B

Digoxin prolongs the refractory period of the AV node. By prolonging the refractory period of the AV node, fewer impulses will be transmitted to the ventricle, and the heart rate will fall. These effects are useful in the treatment of certain arrhythmias. Digoxin slows AV conduction and decreases the rate of the SA node. This effect is desired; however, an overdose may cause excessive slowing of the heart.

The pulse must always be taken prior to administering a dose. The medication should not be given if the dose is below 60 beats per minute.

DIF: Comprehension

REF: Cardiac Glycosides (Digitalis Glycosides [Pharmacologic Effects]) | p. 147 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 9. Hypersalivation is a sign of toxicity for which of the following agents? a. Clonidine b. Digoxin c. Enalapril d. Hydrochlorothiazide e. Nifedipine ANS: B

Early signs of digoxin toxicity include anorexia, nausea and vomiting, and copious salivation. A reduction in the dose level of digoxin usually alleviates these adverse reactions. None of the other choices cause hypersalivation as a sign of toxicity. Clonidine is most likely to cause xerostomia and enalapril the least likely (oral manifestations include dry cough and dysgeusia). Nifedipine and hydrochlorothiazide can produce mild to moderate xerostomia.

DIF: Comprehension REF: Cardiac Glycosides (Digitalis Glycosides [Adverse Reactions]) | p. 147 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 10. The cells of cardiac muscles have an intrinsic rhythm called a. spontaneity. b. automaticity. c. anarchy. d. hierarchy.

ANS: B

The intrinsic rhythm is called automaticity. “Pacemaker” cells spontaneously produce action potentials as they undergo slow spontaneous depolarization during diastole. If any heart muscle cell is left undisturbed and isolated from the rest of the heart with appropriate nutrients and oxygen, each cell will beat spontaneously at its own rate. The intrinsic rhythm of cardiac muscle is not called spontaneity, anarchy, or hierarchy.

DIF: Recall OBJ: 6

REF: Antiarrhythmic Agents (Automaticity) | p. 151 TOP: NBDHE, 6.0. Pharmacology

11. The has the fastest rate of depolarization and therefore directs all the other cells of the heart. a. sinoatrial (SA) node b. atrioventricular (AV) node c. bundle of His d. Purkinje fibers ANS: A

The SA node has the fastest rate of depolarization and therefore directs all the other cells of the heart.

It normally fires impulses approximately 80 times per minute. The SA node is innervated by both the parasympathetic nervous system and the sympathetic nervous system. The SA node sends a message to the AV node via the atrial muscle. The AV node sends the message via the bundle of His to the Purkinje fibers. The Purkinje fibers then send the message to the cardiac muscle cells, to the apex of the ventricles, directing them all to contract as they get the message.

DIF: Recall OBJ: 6

REF: Antiarrhythmic Agents (Automaticity) | p. 151 TOP: NBDHE, 6.0. Pharmacology

12. In a normally functioning heart, the bundle of His receives its electrical input from the a. Purkinje fibers. b. atrioventricular (AV) node. c. sinoatrial (SA) node. d. cardiac muscle.

ANS: B

The AV node sends the message to the Purkinje fibers via the bundle of His. The direction of flow of the impulses to the excitable tissues of the heart is the SA node, AV node, bundle of His, Purkinje fibers, and cardiac muscle. The bundle of His is between the AV node and the Purkinje fibers.

DIF: Comprehension REF: Antiarrhythmic Agents (Automaticity) | p. 151 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 13. Which of the following classes of antiarrhythmics is associated with gingival enlargement? a. Amiodarone b. Calcium channel blockers c. Disopyramide d. Procainamide e. Quinidine ANS: B

Calcium channel blockers and phenytoin are associated with gingival enlargement. Verapamil is the most reported calcium channel blocker associated with gingival enlargement. Amiodarone is associated with liver toxicity, blue skin discoloration, and photosensitivity. Disopyramide is associated with anticholinergic xerostomia. Procainamide is associated with a reversible lupus erythematosus-like syndrome, CNS depression, and xerostomia.

DIF: Recall REF: Antiarrhythmic Agents (Antiarrhythmic Agents [Table 12.11: Management of Dental Patients Taking Antiarrhythmics]) | p. 152 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 14. A patient has a cardiovascular disorder for which a physician prescribes a local anesthetic drug. What

might this cardiovascular disorder be? a. Coronary artery disease b. Hypertension c. Arrhythmia d. Angina pectoris ANS: C

Local anesthetic agents such as procainamide and lidocaine block Na+ channels in the heart and depress parts of the heart that are beating abnormally. Local anesthetic agents are not used in the treatment of coronary artery disease, hypertension, or angina pectoris.

DIF: Application REF: Antiarrhythmic Agents (Antiarrhythmic Agents [Table 12.10: Classification and Mechanism of Action of

the Antiarrhythmics]) | p. 151

OBJ: 7

TOP: NBDHE, 6.0. Pharmacology

15. Which of the following categories of drug is the best choice to relieve the acute symptoms of angina? a. Nitroglycerin (NTG, Nitrostat, Nitrolingual) b. Nitroglycerin (Nitro-Bid) c. Propranolol d. Verapamil (Calan, Isoptin) e. Nifedipine (Procardia) ANS: A

Nitroglycerin (NTG) is by far the most often used nitrate for the management of acute anginal episodes. NTG is also used to prevent anginal attacks induced by stress or exercise. Nitro-Bid is a long-acting nitrate for prophylactic use. Propranolol is a beta-blocker for prophylactic use. Verapamil and nifedipine are calcium channel blockers for prophylactic use as well.

DIF: Comprehension REF: Antianginal Drugs (Nitroglycerin-Like Compounds) | p. 148 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 16. Nitroglycerine (NTG) is used for what cardiovascular disease? a. Atherosclerosis b. Coronary artery disease c. Arrhythmias d. Angina pectoris ANS: D

NTG is a compound that releases nitrite and nitric oxide. These are very strong dilators to veins and arteries. This reduces workload to the heart and can reverse an anginal episode. NTG is not used for atherosclerosis, coronary artery disease, or arrhythmias.

DIF: Recall OBJ: 5

REF: Antianginal Drugs (Nitroglycerin-Like Compounds) | p. 148 TOP: NBDHE, 6.0. Pharmacology

17. Nitroglycerine (NTG) is a(n)

that produces relaxation of vascular smooth muscle throughout the body. a. vasoconstrictor b. vasodilator c. beta-blocker d. angiotensin-converting enzyme inhibitor e. angiotensin receptor blocker ANS: B

NTG produces a systemic relaxation of vascular smooth muscle. Indirectly, there is a reduction in work of the heart produced by the effect on both the venous and the arterial sides of the circulation. By reducing workload on the heart, NTG decreases the oxygen demand with relief or reduction of angina pain. NTG does not belong to the remaining categories of drugs.

DIF: Recall REF: Antianginal Drugs (Nitroglycerin-Like Compounds [Mechanism]) | p. 148 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology

18. The use of nitroglycerin (NTG) is contraindicated if sildenafil (Viagra) has been administered within

24 hours. This is because the NTG-sildenafil combination can precipitate a hypertensive crisis. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Taking NTG within 24 hours of sildenafil is contraindicated. NTG is contraindicated, however, because the combination can cause dangerously low blood pressure (hypotension) rather than hypertension. Sildenafil citrate (Viagra) is a vasodilator that potentiates the vasodilating effects of nitrates. It is contraindicated in persons taking organic nitrates or nitrates such as nitroglycerin, because it may have serious or even fatal effects if the patient has cardiac decompensation.

DIF: Comprehension REF: Antianginal Drugs (Nitroglycerin-Like Compounds [Significant Drug Interactions and Contraindications]) | p. 149 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 19. Nitroglycerin (NTG) should be a. stored in plastic. b. kept in the refrigerator. c. administered once every 5 minutes until the anginal attack is stopped. d. available to the dental team for treatment of an acute anginal attack. e. All of the above.

ANS: D

The dental team should be prepared to treat an acute anginal attack before treating any patient with a history of angina. The patient’s personal NTG tablets or spray should be available and placed on the bracket table in case of an acute attack. The office should have some NTG in their emergency kit as well. NTG is degraded by heat, moisture, and by light. It should be stored in its original brown glass container and tightly closed, because it can be adsorbed by plastic. It should not be refrigerated because condensation of the moisture in the air produces moisture that can reduce its effectiveness. In the case of an attack, NTG should be administered only three times within 15 minutes. If three tablets do not stop the anginal attack, the patient should be taken immediately to the emergency room with a member of the dental team or an emergency medical expert.

DIF: Comprehension REF: Antianginal Drugs (Dental Implications [Treatment of an Acute Anginal Attack]) | p. 150 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 20. To prevent tolerance, prophylactic nitrates should be given with at least a(n) a. week off every month. b. day off every week. c. 8- to 12-hour “vacation” every day. d. 1 hour “vacation” every 12 hours.

ANS: C

Prophylactic nitrates should be given with at least an 8- to 12-hour “vacation” every day. The mononitrate dose form requires a 7-hour “vacation” daily; the first dose is given in the morning and the second dose is given 7 hours later. The “vacation” is taken in order to prevent tolerance. With longterm regular use, tolerance develops to the effects of nitrates. In fact, no difference can be detected between a long-acting nitrate and placebo when taken without a daily “vacation.”

DIF: Recall OBJ: 5

REF: Antianginal Drugs (Nitroglycerin-Like Compounds [Storage]) | p. 149 TOP: NBDHE, 6.0. Pharmacology

21. Which of the following statement is true concerning the use of -adrenergic blocking agents for the

treatment of angina pectoris? a. These drugs block the  response to catecholamine stimulation, thereby reducing both the chronotropic and inotropic effects. b. -Adrenergic blockers are effective in reducing exercise but not stress-induced anginal episodes. c. Adverse effects of -adrenergic blocking agents include tachycardia, headache, and excessive salivation. d. The net result of the use of -adrenergic blocking agents for the treatment of angina pectoris is a reduced myocardial oxygen demand.

ANS: D

The net result of the use of -adrenergic blocking agents for the treatment of angina pectoris is a reduced myocardial oxygen demand. -adrenergic blocking agents block the beta response to catecholamine stimulation, thereby reducing both the chronotropic and inotropic effects. -adrenergic blockers are effective in reducing both exercise- and stress-induced anginal episodes. Adverse effects of -adrenergic blocking agents include bradycardia, heart failure, headache, dry mouth, blurred vision, and unpleasant dreams.

DIF: Comprehension REF: Antianginal Drugs (B-Adrenergic Blocking Agents) | p. 150 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 22. Before administering nitroglycerine (NTG), the dental team should make sure that the patient has not

used a within the past 24 hours. a. phenothiazine b. PDE5 inhibitor c. ranolazine d. guanethidine ANS: B

The administration of any of these drugs with either daily or intermittent doses of any nitrate is contraindicated. If the patient has used one of these drugs, then NTG cannot be given. The dental team should make sure that the patient has not used a phosphodiesterase 5 (PDE5) inhibitor within the past 24 hours.

DIF: Comprehension REF: Antianginal Drugs (Dental Implications [Treatment of an Acute Anginal Attack]) | p. 150 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology

23. If the

tablet of sublingual nitroglycerin (NTG) does not stop the anginal attack, the patient should be taken to the emergency room. a. first b. second c. third d. fourth e. fifth ANS: C

The dental office should have a supply of sublingual NTG for acute emergencies. One tablet can be administered at once, followed in 5 minutes by another, and in another 5 minutes by a third tablet. If these tablets do not stop the anginal attack, the patient should be taken to the emergency room. The recommendation for the number of tablets of sublingual nitroglycerin to be administered before the patient is taken to the emergency room is specific. Only one of these choices is correct.

DIF: Application REF: Antianginal Drugs (Dental Implications [Treatment of an Acute Anginal Attack]) | p. 150 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 24. Which of the following is the most common cardiovascular disease? a. Heart failure b. Cardiac arrhythmia c. Angina d. Hypertension ANS: D

Hypertension is the most common cardiovascular disease, affecting some 108 million Americans and over 1.3 billion individuals worldwide. The prevalence of hypertension increases with age. Overall men have a higher prevalence than women, however, it is higher among women than men for those over 60 years of age. Data from the Framingham Heart Study suggested that individuals with normal blood pressure at age 55 have a 90% lifetime risk for developing hypertension. Statistically, it is likely that many dental patients will be suffering from hypertension.

DIF: Recall REF: Hypertension | p. 134 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

25. Which of the following statements is true regarding hypertension? a. High blood pressure eventually damages internal organs. b. Complications of hypertension are greatly increased with concomitant smoking. c. In most cases of hypertension, the cause can be identified and associated with a

specific disease process. d. Both A and B are true. e. Both B and C are true.

ANS: D

High blood pressure damages organs and untreated hypertensive patients are more likely to have kidney and heart disease and cardiovascular problems. Complications of hypertension are greatly increased with concomitant smoking. In approximately 10% of hypertensive patients, the cause can be identified and associated with a specific disease process involving the endocrine or renal systems.

DIF: Application REF: Hypertension | p. 134 TOP: NBDHE, 6.0. Pharmacology 26. Less than a. 10 b. 25 c. 50 d. 75

OBJ: 2

% of people with hypertension are properly treated.

ANS: C

Less than half of all patients with hypertension are properly treated. Early detection and treatment with drug therapy reduces the possibility of damage to vital organs and extends the patient’s lifetime. If hypertensive patients are properly treated, meaning their blood pressure is normalized, their risk of complications is equal to that of the patient without hypertension.

DIF: Recall REF: Hypertension | p. 135 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

27. Essential hypertension is a. of unknown cause. b. iatrogenic hypertension. c. precipitated by another disorder. d. a rapidly developing form of hypertension, requiring aggressive therapy.

ANS: A

Approximately 85% to 90% of patients diagnosed with hypertension have essential, idiopathic, or primary hypertension, which tends to be familial and may be the result of the interaction between environmental and genetic factors. These terms all stand for hypertension from an unknown cause.

Iatrogenic hypertension would be hypertension caused as a consequence of treatment. Hypertension precipitated by another disorder would be secondary hypertension. A rapidly developing hypertension is malignant hypertension.

DIF: Comprehension REF: Hypertension | p. 134 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 28. Common adverse reactions associated with thiazides include a. hypokalemia and hypouricemia. b. hyperkalemia and hypouricemia. c. hypokalemia and hyperuricemia. d. hyperkalemia and hyperuricemia.

ANS: C

Common adverse reactions associated with thiazides include hypokalemia secondary to sodiumpotassium exchange and hyperuricemia due to inhibition of uric acid secretion. Hyperglycemia, hyperlipidemia, and hypercalcemia and anorexia are other side effects. The thiazide diuretics inhibit the resorption of sodium from the distal convoluted tubule and part of the ascending loop of Henle from the kidney. Water and chloride ions passively accompany the sodium, producing diuresis.

Because more sodium is presented to the site of sodium-potassium exchange, there is also an increase in potassium excretion, producing hypokalemia. Hyperuricemia is due to an inhibition of uric acid secretion.

DIF: Recall OBJ: 2

REF: Hypertension (Diuretic Agents [Thiazide Diuretics]) | p. 139 TOP: NBDHE, 6.0. Pharmacology

29. Which of the following is the most important dental drug interaction with the thiazide diuretics? a. Aspirin b. Nonsteroidal antiinflammatory drugs (NSAIDs) c. Penicillin d. Chlorhexidine ANS: B

The most important dental drug interaction with the thiazides is interaction with the NSAIDs. NSAIDs can reduce the antihypertensive effect of the thiazide diuretics. However, NSAIDs can increase the risk for cardiovascular adverse events, especially in those with cardiovascular disease. As a result, they should not be used in this group of people. The other choices are not representative of the most important dental drug interaction with thiazide diuretics.

DIF: Recall OBJ: 2

REF: Hypertension (Diuretic Agents [Thiazide Diuretics]) | p. 139 TOP: NBDHE, 6.0. Pharmacology

30. Eating bananas when taking thiazide diuretics will a. deplete calcium. b. prevent diuresis. c. replenish potassium. d. inhibit the drug’s metabolism.

ANS: C

A characteristic adverse effect of thiazide diuretics is the loss of potassium and potential hypokalemia.

Bananas are rich in potassium and are effective at replenishing this ion. Bananas do not deplete calcium, prevent diuresis, or inhibit the metabolism of thiazide diuretics.

DIF: Application OBJ: 2

REF: Hypertension (Diuretic Agents [Thiazide Diuretics]) | p. 138 TOP: NBDHE, 6.0. Pharmacology

31. Which diuretic acts at the ascending loop of Henle of the kidney nephron to cause rapid diuresis? a. Hydrochlorothiazide b. Triamterine c. Furosemide d. Spironolactone ANS: C

Furosemide is considered a “loop diuretic” because it works at the ascending loop of Henle. It acts before the other diuretics listed and can cause a more rapid and pronounced diuresis.

Hydrochlorothiazide primarily works in the distal convoluted tubule, whereas triamterine and spironolactone have their site of action in the late distal convoluted tubule and collecting duct.

DIF: Comprehension REF: Hypertension (Diuretic Agents [Loop Diuretics]) | p. 139 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

32. Which of the following groups of diuretics are called the “puny” diuretics? a. Thiazide b. Loop c. Potassium-sparing d. Both A and B e. Both B and C ANS: C

Potassium-sparing diuretics are “puny” diuretics with “potassium-catching” ability. Individual members of this group have different mechanisms of action, but all have weak diuretic action. The potassium-sparing diuretics act at different sites in the kidney than the thiazide diuretics. The thiazide diuretics are among the most commonly used agents for the treatment of hypertension. Thiazides can cause hypokalemia and sensitize the myocardium to developing arrhythmias. Loop diuretics are considered the “strong cousins” of the thiazide diuretics. Like thiazides, loop diuretics inhibit the reabsorption of sodium with a concurrent loss of fluids.

DIF: Comprehension REF: Hypertension (Diuretic Agents [Potassium-Sparing Diuretics]) | p. 139 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 33. a. b. c. d. e.

should not be given to persons taking potassium supplements because hyperkalemia will occur.

Thiazides -Blockers Angiotensin-converting enzyme inhibitors (ACEIs) Angiotensin receptor blockers (ARBs) Calcium channel blockers

ANS: C

ACEIs can cause hyperkalemia, and potassium supplements and potassium-sparing diuretics should not be used with these drugs. ACEIs should not be given to persons taking potassium supplements.

Patients taking potassium supplements should be questioned about their use of diuretics, and the possibility of cardiovascular disease should be explored when a drug history is taken.

DIF: Recall OBJ: 2

REF: Hypertension (Diuretic Agents [Potassium Salts]) | p. 140 TOP: NBDHE, 6.0. Pharmacology

34. 1-Receptor stimulation is associated with a. vasodilation in skeletal muscles. b. bronchodilation in pulmonary tissues. c. a decrease in heart rate. d. an increase in cardiac contractility.

ANS: D

1-Receptor stimulation is associated with an increase in heart rate, cardiac contractility, and AV conduction. Stimulation of 2-receptors produces vasodilation in skeletal muscles and bronchodilation in the pulmonary tissues. An easy way to remember this is that humans have one heart and two lungs.

DIF: Comprehension REF: Hypertension (Beta-Adrenergic Blocking Agents) | p. 142 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

35. Which beta-adrenergic blocking agent has partial agonist activity and causes some alpha-stimulation

while blocking catecholamine action? a. Atenolol b. Acebutolol c. Metoprolol d. Carvedilol ANS: B

Pindolol and acebutolol have partial agonist activity and cause some -stimulation while blocking catecholamine action. Pindolol is nonselective, whereas acebutolol is beta-1 selective. Atenolol and metoprolol are 1-selective full antagonists. Carvedilol is a nonspecific -blocker with -blocking activity as well.

DIF: Recall OBJ: 2

REF: Hypertension (Beta-Adrenergic Blocking Agents) | p. 142 TOP: NBDHE, 6.0. Pharmacology

36. Which of the following agents can worsen asthma? a. Propranolol (Inderal) b. Calcium channel blocker c. ACEIs d. Anticholinergics ANS: A

In usual doses, the selective, or specific, beta-adrenergic receptor blocking drugs, such as metoprolol, block the beta 1-receptors more than the beta 2-receptors. The selective beta-blockers have some advantages in patients who may have preexisting bronchospastic disease, such as asthma, because they do not block the airway’s bronchodilating action. Propranolol is a nonselective beta-adrenergic antagonist. It can inhibit lung beta 2-receptors, which are involved in bronchodilation.

DIF: Application OBJ: 2

REF: Hypertension (Beta-Adrenergic Blocking Agents) | pp. 142-143 TOP: NBDHE, 6.0. Pharmacology

37. -Adrenergic blockers lower blood pressure primarily by a. reducing peripheral resistance. b. decreasing cardiac output. c. lowering plasma volume. d. lowering plasma renin levels.

ANS: B

-Adrenergic blockers lower blood pressure primarily by decreasing cardiac output. Other effects that may contribute to their antihypertensive effect include a lowering of plasma renin levels, a reduction in plasma volume and venous return, a decrease in sympathetic outflow from the central nervous system (CNS), and a reduction in peripheral resistance.

DIF: Recall OBJ: 2

REF: Hypertension (Beta-Adrenergic Blocking Agents) | p. 143 TOP: NBDHE, 6.0. Pharmacology

38. Nonselective -blockers can have a drug interaction with epinephrine, causing a two- to fourfold

increase in vasopressor response. A gingival retraction cord containing epinephrine may be used, however. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

In patients with cardiovascular disease or higher blood pressure, the amount of epinephrine given to patients taking nonspecific -blockers should be limited to the cardiac dose unless careful bloodpressure monitoring accompanies the use of larger doses. Neither gingival retraction cord containing epinephrine nor 1:50,000 epinephrine should be used. The amount of caution required with this drug interaction depends on the patient’s underlying cardiovascular disease, if any increase in blood pressure, and the dose of the -blocker the patient is taking. The dentist should avoid using gingival retraction cord that contains epinephrine because these cords contain epinephrine that is highly concentrated. It can be quickly absorbed into sulcular tissue and lead to tachycardia and elevated blood pressure.

DIF: Comprehension REF: Hypertension (Beta-Adrenergic Blocking Agents [Dental Drug Interactions]) | p. 143 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 39. Which of the following is a -adrenergic blocking drug that also has -receptor blocking activity? a. Atenolol b. Labetalol c. Doxazosin d. Minoxidil ANS: B

Labetalol and Carvedilol are both -blockers with -blocking activity. Atenolol is a -adrenergic blocker. Doxazosin is an -adrenergic blocker. Minoxidil is a vasodilator.

DIF: Recall REF: Hypertension (Beta-Adrenergic Blocking Agents [Alpha- and Beta-Adrenergic Blocking Drug]) | p. 143 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 40. Which of the following categories of antihypertensive agents end in the suffix -dipine? a. Diuretic agents b. -Adrenergic blocking agents c. Calcium channel blocking agents d. Angiotensin receptor blockers (ARBs) ANS: C

Many calcium channel blocking agents end in the suffix -dipine. These are used to treat hypertension and other cardiac conditions such as arrhythmias and angina. Common calcium channel blockers include the drugs verapamil, nifedipine, and diltiazem. Thiazide diuretics end in the suffix -thiazide.

Examples include chlorothiazide and hydrochlorothiazide. -Adrenergic blockers end in the suffix olol. Examples include atenolol, metoprolol, and propranolol. ARBs end in the suffix -artan. Examples include losartan, olmesartan, and valsartan.

DIF: Recall OBJ: 2

REF: Hypertension (Calcium Channel Blocking Agents) | p. 141 TOP: NBDHE, 6.0. Pharmacology

41. Each of the following effects is characteristic of channel-blocking agents except one. Which is the

exception? a. Reduction in afterload on the heart b. Inhibition of calcium influx c. Decrease in cardiac contractility d. Orthostatic hypotension e. Peripheral edema ANS: D

Orthostatic hypotension is an uncommon effect of calcium channel blocker treatment. Calcium channel blockers dilate coronary and peripheral arteries and arterioles, thereby reducing afterload on the heart. They act by blocking calcium ion influx. Their effect on the heart leads to a decrease in cardiac contractility. The decreased contractility and increased arteriolar dilation can result in peripheral edema.

DIF: Comprehension REF: Hypertension (Calcium Channel Blocking Agents [Mechanism]) | pp. 141-142 | Hypertension (Calcium Channel Blocking Agents [Pharmacologic Effects]) | p. 142 | Hypertension (Calcium Channel Blocking Agents [Adverse Reactions]) | p. 142OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 42. Many end in the suffix -pril. a. -adrenergic blockers b. calcium channel blockers c. angiotensin-converting enzyme inhibitors (ACEIs) d. angiotensin receptor blockers (ARBs) ANS: C

Many ACEIs end in the suffix -pril. ACEIs prevent the conversion of angiotensin I to angiotensin II. ACEIs are commonly used as antihypertensives. Examples include captopril, enalapril, and lisinopril. -adrenergic blockers end in the suffix -olol. Many calcium channel blockers end in the suffix -dipine.

ARBs end in the suffix -artan.

DIF: Recall REF: Hypertension (Diuretic Agents [Angiotensin-Converting Enzyme Inhibitors]) | p. 140 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 43. Which class of agents is of special benefit to a diabetic with nephropathy? a. -Adrenergic blockers

b. Calcium channel blocker (CCB) c. Angiotensin-converting enzyme inhibitors (ACEIs) d. Anticholinergics ANS: C

ACEIs retard the progression of diabetic nephropathy whether hypertension is present or not. The remaining drugs are not thought to retard the progression of diabetic nephropathy. The ACEIs may be used alone or in combination with a -blocker, thiazide diuretic, or CCB. DIF: Comprehension REF: Hypertension (Diuretic Agents [Angiotensin-Converting Enzyme Inhibitors]) | p. 140 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 44. Angiotensin receptor blockers (ARBs) end with the suffix a. -olol. b. -dipine. c. -pril. d. -artan.

ANS: D

ARBs end with the suffix -artan. The ARBs act by attaching to the angiotensin II receptor and blocking the effect of angiotensin II. Losartan is the prototype. Many -adrenergic blockers end in olol. Many calcium channel blockers end in -dipine. ACEIs end in -pril.

DIF: Recall OBJ: 2

REF: Hypertension (Angiotensin Receptor Blockers) | p. 140 TOP: NBDHE, 6.0. Pharmacology

45. NSAIDs can antagonize the effects of which of the following antihypertensive medications? a. Angiotensin-converting enzyme inhibitors (ACEIs) b. -Adrenergic antagonists c. Calcium channel blockers d. Loop diuretics e. Centrally acting hypertensive agents ANS: A

The antihypertensive effectiveness of ACEIs is reduced by administration of the NSAIDs, which is a result of the blockage of bradykinin-mediated vasodilation, which is at least in part prostaglandinmediated. NSAIDs can increase the risk for cardiovascular adverse events, especially in those with cardiovascular disease. As a result, they should not be used in this group of people. NSAIDs do not antagonize the antihypertensive actions of -adrenergic antagonists, calcium channel blockers, loop diuretics, or centrally acting hypertensive agents.

DIF: Comprehension REF: Hypertension (Diuretic Agents [Angiotensin-Converting Enzyme Inhibitors]) | p. 140 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 46. Which of the following agents is an 1-adrenergic receptor antagonist? a. Amlodipine (Norvasc) b. Benazepril (Lotensin) c. Candesartan (Atacand)

d. Terazosin (Hytrin) e. Atenolol (Tenormin) ANS: D

1-Adrenergic blocking agents end in -zosin. Amlodipine is a calcium channel blocker, benazepril is an angiotensin-converting enzyme inhibitor, candesartan is an angiotensin receptor blocker, and atenolol is a -adrenergic blocker.

DIF: Recall OBJ: 2

REF: Hypertension (Alpha1-Adrenergic Blocking Agents) | p. 143 TOP: NBDHE, 6.0. Pharmacology

47. Which of the following categories of agents may be used to treat both hypertension and benign

prostatic hypertrophy? a. Diuretic agents b. -Adrenergic blocking agents c. 1-Adrenergic blocking agents d. Calcium channel blocking agents ANS: C

1-Adrenergic blocking agents result in reduction of urethral resistance and pressure, bladder outlet resistance, and urinary symptoms. This effect accounts for their use in management of older males who have an enlarged prostate gland. Surgery can often be avoided in those patients who are managed by drug therapy. If a male has both hypertension and benign prostatic hypertrophy (BPH), then one can “kill two birds with one stone.” The remaining agents are not associated with treatment of both hypertension and benign prostatic hypertrophy.

DIF: Comprehension REF: Hypertension (Alpha1-Adrenergic Blocking Agents [Mechanism]) | p. 143 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 48. Which agent is most likely to cause xerostomia? a. Losartan b. Clonidine c. Enalapril d. Atenolol ANS: B

The incidence of xerostomia is highest with clonidine. The oral effects of clonidine include a high incidence of xerostomia (40%), parotid gland swelling, and pain. Another side effect is dysgeusia.

Losartan, enalapril, and atenolol are not known to cause excessive xerostomia.

DIF: Application OBJ: 2

REF: Hypertension (Central Alpha-Adrenergic Agonists [Clonidine]) | p. 144 TOP: NBDHE, 6.0. Pharmacology

49. Severe hypotension and reflex tachycardia are caused by combination of sympathomimetics, such as

epinephrine, with which antihypertensive agent class? a. Calcium channel blockers b. 1-Adrenergic blocking agents c. Angiotensin receptor blockers (ARBs) d. Potassium-sparing diuretics

ANS: B

The sympathomimetics can increase the antihypertensive effects of doxazosin. The 1-blockers prevent the 1-agonist effects (vasoconstriction) of epinephrine, leaving the 1- and 2-agonist effects (vasodilation) to predominate. The combined vasodilation can result in severe hypotension and reflex tachycardia. No clinically relevant drug interactions have been found between sympathomimetics and calcium channel blockers, ARBs, or potassium-sparing diuretics.

DIF: Comprehension REF: Hypertension (Alpha1-Adrenergic Blocking Agents [Dental Drug Interactions]) | p. 143 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 50. Each of the following agents is associated with development of gingival hypertrophy except one.

Which is the exception? a. Verapamil b. Phenytoin c. Clonidine d. Felodipine ANS: C

Gingival hypertrophy is not an adverse effect produced by clonidine administration. Phenytoin is an anticonvulsant well known for its hypotrophic effect on the gingiva. Verapamil and felodipine are calcium channel blockers, another drug class known for high incidence of gingival hypertrophy.

DIF: Application OBJ: 2

REF: Hypertension (Central Alpha-Adrenergic Agonists [Clonidine]) | p. 144 TOP: NBDHE, 6.0. Pharmacology

51. A serious lupus-like reaction is associated with which cardiovascular drug? a. Clonidine b. Hydralazine c. Isosorbide dinitrate d. Spironolactone ANS: B

Hydralazine is known to cause a serious toxic reaction producing symptoms such as those of systemic lupus erythematosus. Therapy with clonidine, isosorbide dinitrate, or spironolactone is not associated with a lupus-like reaction.

DIF: Recall REF: Hypertension (Central Alpha-Adrenergic Agonists [Direct Vasodilators]) | p. 144 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 52. Patients taking antihypertensive agents who have been supine for some time should be slowly raised

from that position. They should dangle their legs over the side of the chair and wiggle them before rising to the standing position. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: A

Many antihypertensive drugs cause orthostatic hypotension to some extent or another. Getting up quickly can lead to pooling of blood in the extremities and lightheadedness. This can be prevented by getting one’s circulation moving and getting up slowly. When a patient has been in a supine position and suddenly rises to an upright position, a sudden fall in blood pressure may occur. Guanethidine causes this problem often; other agents produce variable amounts of orthostatic hypotension.

DIF: Comprehension REF: Hypertension (Management of the Dental Patient Taking Antihypertensive Agents [Adverse Reactions]) | p. 144 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 53. Which of the following statements is true concerning hyperlipidemia and cholesterol? a. Hyperlipidemia includes elevations in cholesterol or triglycerides and is associated b. c. d. e.

with the development of arteriosclerosis.

High-density lipoprotein (HDL) is good cholesterol.

Foam cells become filled with lipid.

Both A and B are correct.

Both B and C are correct.

ANS: D

Hyperlipidemia includes elevations in cholesterol or triglycerides and is associated with the development of arteriosclerosis, although the exact correlation is unknown. HDLs are known as good cholesterol because they have the lowest cholesterol content and are considered to be beneficial. Foam cells become filled with cholesterol esters. Accumulation of these esters leads to deposition of lipids in the arteries. Collagen and fibrin also accumulate, occluding the vessels.

DIF: Comprehension REF: Antihyperlipidemic Agents | p. 152 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 54. The newest guidelines from the ACC/AHA recommend using HMG-coA reductase inhibitors (statins)

as the drugs of first choice for treating patients with atherosclerotic cardiovascular disease based on a. a total cholesterol level of over 240 mg/dL. b. a low-density lipoprotein level over 190 mg/dL. c. the patient’s estimated 10-year atherosclerotic cardiovascular disease risk. d. poor lifestyle factors such as being overweight and smoking.

ANS: C

The focus is on the patients’ estimated 10-year atherosclerotic cardiovascular disease risk. The newest guidelines from the ACC/AHA no longer recommend using specific cholesterol targets for deciding treatment for patients with elevated cholesterol levels. Lifestyle modifications remain a critical component of lowering lipid levels and should be used in conjunction with cholesterol-lowering drugs.

DIF: Recall OBJ: 8

REF: Antihyperlipidemic Agents | p. 152 TOP: NBDHE, 6.0. Pharmacology

55. Which of the following is the first choice of therapy for most patients with atherosclerotic heart disease

and elevated cholesterol levels? a. Fenofibrate b. Niacin c. Colestipol (Colesevelam)

d. Omega-3 fish oil e. 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitor ANS: E

The HMG Co-A reductase inhibitors (statins) are the first choice of therapy for most patients with atherosclerotic heart disease and elevated cholesterol levels and are further categorized as highintensity and moderate-intensity statins. Statins can be used in combination with fenofibrate, niacin, colesevelam, or omega-3-fatty acids to lower triglycerides and increase HDLs in addition to lowering LDLs. DIF: Recall REF: Antihyperlipidemic Agents (3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors) | p. 152 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 56. When a physician finds out that his female patient wishes to start a family, he decides to change her

cholesterol-lowering medication. He changes her medication from a. niacin to simvastatin. b. simvastatin to atorvastatin. c. simvastatin to niacin. d. gemfibrozil to losartan.

ANS: C

Of the drugs used to treat hyperlipidemia, the statins are very effective, but are contraindicated in women who are pregnant or nursing. A medication change to any statin would be contraindicated in women wishing to conceive. Losartan is not used to treat hyperlipidemia.

DIF: Application REF: Antihyperlipidemic Agents (3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors) | p. 152 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 57. 3-Hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase is inhibited by a. pravastatin. b. ramipril. c. nifedipine. d. ezetimibe.

ANS: A

Statins such as pravastatin are HMG CoA reductase inhibitors. They lower serum cholesterol. Ramipril is an ACEI, nifedipine is a calcium channel blocker, and ezetimibe (Zetia) is a cholesterol-lowering agent that acts by inhibiting cholesterol absorption from the small intestine.

DIF: Application REF: Antihyperlipidemic Agents (Table 12.12: Effect of Antihyperlipidemic Agents on Serum Lipids) | p. 154 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 58. Which of the following statements is true of ezetimibe? a. It is an HMG Co-A reductase inhibitor. b. This drug decreases total cholesterol, HDL cholesterol, and decreases HDL

cholesterol levels.

c. It is currently available in combination with simvastatin or atorvastatin to treat

cholesterol with two different mechanisms of action. d. Ezetimibe/simvastatin has been found to lower low-density lipoprotein (LDL)

cholesterol and has a marked effect on plaque buildup.

ANS: C

Ezetimibe currently comes in combination with simvastatin or atorvastatin to treat cholesterol from two different mechanisms of action. Ezetimibe (Zetia) works by inhibiting the intestinal absorption of cholesterol. This drug decreases total cholesterol, LDL cholesterol, and increases HDL cholesterol levels.

DIF: Comprehension REF: Antihyperlipidemic Agents (Inhibitors of Intestinal Absorption of Cholesterol) | p. 153 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 59. Niacin works by a. inhibiting HMG-CoA reductase. b. inhibiting the intestinal absorption of cholesterol. c. inhibiting the secretion of very-low-density lipoproteins (VLDL-Cs) without

accumulation of triglycerides in the liver. d. increasing lipolysis of triglycerides, decreasing lipolysis in adipose tissue, and

inhibiting secretions of VLDL-Cs from the liver.

ANS: C

Niacin inhibits the secretion of VLDL-Cs without accumulation of triglycerides in the liver. This reduces LDL synthesis. The statins lower cholesterol levels by inhibiting HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis. Ezetimibe works by inhibiting the intestinal absorption of cholesterol. Gemfibrozil works by increasing lipolysis of triglycerides, decreasing lipolysis in adipose tissue, and inhibiting secretion of VLDL-Cs from the liver.

DIF: Comprehension REF: Antihyperlipidemic Agents (Niacin) | p. 153 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 60. Which agent reduces serum cholesterol by increasing its utilization for bile acid synthesis? a. Niacin b. Atorvastatin c. Gemfibrozil d. Cholestyramine e. Clopidogrel ANS: D

Cholestyramine is a bile acid-binding resin that inhibits the reabsorption of bile acids from the jejunum and ileum back into the circulation. The body needs to replace these lost bile acids and increases its utilization of cholesterol for this purpose. Niacin lowers cholesterol levels by inhibiting the secretion of VLDLs without accumulation of triglycerides in the liver. Atorvastatin is an HMG CoA reductase inhibitor, gemfibrozil increases the lipolysis of triglycerides and is a peroxisome proliferator-activated receptor (PPAR-) agonist. Clopidogrel is not a cholesterol-lowering agent.

DIF: Recall OBJ: 8

REF: Antihyperlipidemic Agents (Cholestyramine) | p. 153 TOP: NBDHE, 6.0. Pharmacology

61. Which of the following antihyperlipidemic agents can promote gallstone formation? a. HGM CoA reductase inhibitors b. Niacin c. Cholestyramine d. Gemfibrozil ANS: D

Gemfibrozil causes fewer gastrointestinal complaints than the bile acid-binding drugs, but it can promote gallstone formation (cholelithiasis). An altered sense of taste and hyperglycemia have been reported with the use of gemfibrozil. One of the other choices is associated with gallstone formation.

DIF: Recall OBJ: 8

REF: Antihyperlipidemic Agents (Fibric Acid Derivatives) | p. 154 TOP: NBDHE, 6.0. Pharmacology

62. Long chain omega-3 polyunsaturated fatty acids can decrease fasting triglyceride concentrations by a. increasing hepatic very-low-density-lipoprotein (VLDL) production. b. increasing the conversion of acetyl-CoA to fatty acids. c. increasing beta-oxidation of fatty acids and inhibiting phosphatidic acid (PA). d. decreasing high-density-lipoprotein (HDL) levels.

ANS: C

Omega-3 fatty acids are thought to lower triglyceride levels by decreasing hepatic VLDL and triglyceride production and secretion by decreasing the enzymatic conversion of acetyl-CoA to fatty acids, increasing -oxidation of fatty acids, inhibiting PA, the enzyme that catalyzes the conversion of PA to diacylglycerol, and inhibiting DGAT, the enzyme that catalyzes the final step in TG synthesis.

Long-term use may increase HDL levels.

DIF: Recall OBJ: 8

REF: Antihyperlipidemic Agents (Fish Oils) | pp. 154-155 TOP: NBDHE, 6.0. Pharmacology

63. There is a danger of if the dose of anticoagulant is too small. a. embolism b. hemorrhage c. chronic obstructive pulmonary disease d. angina ANS: A

A danger of embolism exists if the dose is too small. Hemorrhage may occur if the dose of the anticoagulant is too large. Chronic obstructive pulmonary disease (COPD) is characterized by irreversible airway obstruction, which occurs with either chronic bronchitis or emphysema. With severe COPD, a patient can develop pulmonary hypertension, increasing the risk for cardiac arrhythmias. Angina pectoris is a common cardiovascular disease characterized by pain or discomfort in the chest radiating to the left arm and shoulder. Most adverse reactions associated with NTG occur because of its effect on vascular smooth muscle. Severe headaches are often reported after the use of NTG. DIF: Comprehension REF: Drugs that Affect Blood Coagulation (Anticoagulants [Hemostasis]) | p. 155 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology

64. Of the vitamin K–dependent clotting factors, which has the shortest circulating half-life? a. Factor II b. Factor VII c. Factor VIII d. Factor IX e. Factor X ANS: B

Clotting factor VII has a half-life of 6 hours. Endogenous clotting factors II, IX, and X have half-lives that are 60, 24, and 40 hours, respectively. Factor VIII has a half-life of 10 to 12 hours. It is not a vitamin K–dependent clotting factor.

DIF: Recall REF: Drugs that Affect Blood Coagulation (Oral Anticoagulants [Warfarin]) | p. 156 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology 65. A patient taking warfarin (Coumadin) may experience interactions with which of the following? a. Phenobarbital b. Erythromycin c. Aspirin d. All of the above ANS: D

Warfarin is notorious for interacting with other drugs. Phenobarbital induces its metabolism and decreases circulating warfarin levels. Erythromycin inhibits its metabolism and increases the risk of bleeding crises. Aspirin can displace warfarin from plasma protein sites and increase warfarin’s free serum levels. Aspirin’s antithrombotic action is also additive with warfarin’s anticoagulant action.

DIF: Application REF: Drugs that Affect Blood Coagulation (Oral Anticoagulants [Warfarin]) | pp. 155-156 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology 66. The therapeutic target international normalized ratio (INR) for most indications, such as

thrombophlebitis, is a. less than 1. b. between 2 and 3. c. between 3.5 and 4.5. d. over 4.5.

ANS: B

The therapeutic target INR for most indications, such as thrombophlebitis, or atrial fibrillation is between 2 and 3. For patients with a prosthetic heart valve, the target INR is between 2.5 and 3.5. The INR can range from 1 to 4, although it can reach higher levels with overdose. The remaining choices do not correctly depict the target INR for most indications.

DIF: Recall REF: Drugs that Affect Blood Coagulation (Oral Anticoagulants [Warfarin]) | p. 156 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology

67. The presence of

in the oral cavity can be a sign of an adverse effect associated with the oral

anticoagulants. a. lichen planus b. petechial hemorrhages c. linear gingival erythema d. hairy tongue ANS: B

The most common adverse effects associated with the oral anticoagulants are various forms of bleeding, including hemorrhage. One should look for petechial hemorrhages in the oral cavity.

Ecchymoses can occur, even without concomitant trauma. The etiology of lichen planus is unknown, but current hypotheses include a viral infection, an autoimmune disease, and a hypersensitivity reaction to an unknown agent. Linear gingival erythema is associated with immune deficiencies. This form of gingivitis typically does not respond to improved plaque control. Most believe this pattern represents an unusual pattern of candidiasis. The cause of hairy tongue is uncertain. Possible associated factors include antibiotics, poor oral hygiene, general debilitation, radiation therapy, use of oxidizing mouthwashes or antacids, or an overgrowth of fungal or bacterial organisms.

DIF: Comprehension REF: Drugs that Affect Blood Coagulation (Oral Anticoagulants [Warfarin]) | p. 156 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology 68. Which of the following agents has the most serious drug interaction with warfarin? a. Omeprazole b. Aspirin c. Digitalis d. Lomotil ANS: B

Patients taking warfarin should not be given aspirin or aspirin-containing products because bleeding episodes or fatal hemorrhages can occur. Aspirin causes hypoprothrombinemia and alters platelet adhesiveness. Aspirin can also irritate the gastrointestinal tract, which might bleed more in a patient taking warfarin. Another factor in the aspirin-warfarin interaction is related to protein binding or drugs.

Aspirin displaces bound warfarin. The other choices are not the agent with the most serious drug interaction with warfarin.

DIF: Recall REF: Drugs that Affect Blood Coagulation (Oral Anticoagulants [Warfarin]) | p. 156 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology 69. Which of the following drugs is a direct inhibitor of thrombin? a. Rivaroxaban (Xarelto) b. Dabigatran (Pradaxa) c. Clopidogrel (Plavix) d. Ticlopidine (Ticlid) e. Alteplase (Activase) ANS: B

Dabigatran (Pradaxa) is a direct thrombin inhibitor. Thrombin enables the conversion of fibrinogen to fibrin during the coagulation cascade, which results in the formation of the clot or thrombus. This drug directly prevents the clot from forming. Rivaroxaban (Xarelto) prevents coagulation by selectively blocking the active site of factor XA and does not require a cofactor (Antithrombin III) for activity.

Clopidogrel (Plavix) is an inhibitor of adenosine diphosphate (ADP)-induced platelet aggregation, which results in prolonged bleeding time. Ticlopidine (Ticlid) is an irreversible inhibitor of ADPinduced platelet aggregation, which results in prolonged bleeding time. Alteplase (Activase) is a thrombolytic drug that promotes the conversion of plasminogen to plasmin, the natural clot-resolving enzyme.

DIF: Recall REF: Drugs that Affect Blood Coagulation (Direct Thrombin Inhibitor) | p. 157 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 70. Each of the following agents inhibits platelet function except one. Which is the exception? a. Clopidogrel b. Dipyridamole c. Ticlopidine d. Aspirin ANS: B

Dipyridamole is used to prolong the life of platelets in patients with prosthetic heart valves.

Clopidogrel, ticlopidine, and aspirin all inhibit adenine dinucleotide phosphate–induced platelet aggregation.

DIF: Recall OBJ: 10

REF: Thienopyridines (Dipyridamole) | p. 158 TOP: NBDHE, 6.0. Pharmacology

71. Some studies have found that the presence of periodontal disease predicts an increase in morbidity and

mortality resulting from cardiovascular disease. Other studies have failed to show a relationship. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: A

Studies both support and reject such a relationship. Researchers do agree that more studies are needed.

Several studies correlate the patient’s periodontal condition to cardiovascular disease over time.

Researchers and government agencies continue to investigate the possible relationship between periodontal disease and cardiovascular disease.

DIF: Comprehension REF: Dental Implications of Cardiovascular Disease (Periodontal Disease and Cardiovascular Disease) | p. 134 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 72. Blood returning from the peripheral circulation enters the a. left atrium. b. left ventricle. c. right atrium. d. right ventricle.

ANS: C

If the right side of the heart fails, then the right ventricle is unable to remove all the blood from the right side of the heart. Right-sided heart failure causes systemic congestion. Blood goes from the peripheral circulation to the right atrium, to the right ventricle, to the lungs for oxygenation, to the left atrium, to the left ventricle, and is then pumped at high pressure into the arteries. If the left side of the heart fails, the blood backs up into the pulmonary circulation (lungs).

DIF: Recall REF: Heart Failure | p. 145 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

73. Which is the treatment of choice for the treatment of heart failure (HF)? a. Diuretics b. Angiotensin-converting enzyme inhibitors c. Angiotensin receptor blockers d. Angiotensin II receptor neprilysin inhibitor e. If channel inhibitor ANS: B

The most current guidelines from the ACC and the AHA recommend prescribing an ACEI for patients with symptomatic (stage C) HF and for asymptomatic patients with HFrEF of 35% or a history of MI unless there are contraindications to an ACEI. ACEIs improve symptoms in patients with HF within a period of 4 to 12 weeks, decrease the incidence of hospitalization and MI, and prolong survival. ACE inhibitors are an initial treatment option for HF. DIF: Recall REF: Angiotensin II Receptor Neprilysin Inhibitor (Angiotensin-Converting Enzyme Inhibitors) | p. 145 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 74. Ivabradine (Corlanor) acts by inhibiting an ion channel in the a. bundle of His. b. sinoatrial node. c. Purkinje fibers. d. right atrium. e. left atrium.

ANS: B

Ivabradine works by inhibiting the If ion channel in the sinoatrial note. Blocking this channel reduces cardiac pacemaker activity and slows the heart rate. Ivabradine does not block an ion channel in the bundle of His, Purkinje fibers, or right or left atrium of the heart.

DIF: Recall OBJ: 3

REF: Heart Failure (Treatment of Heart Failure [If Channel Inhibitor]) | p. 147 TOP: NBDHE, 6.0. Pharmacology

75. GoNitro is administered to the patient as a a. tablet. b. spray. c. powder. d. injection.

ANS: C

GoNitro is supplied in single-use packets of powder that contain 0.4 mg of nitroglycerin, which should be stored at room temperature. GoNitro is not supplied as a tablet, spray, or injection. It is a form of sublingual (SL) NTG, meaning it is meant to be placed under the tongue.

DIF: Recall REF: Antianginal Drugs (Nitroglycerin-Like Compounds [Mechanism]) | pp. 148-149 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 76. -Methyldopa (Aldomet) and clonidine (Catapres [TTS]) act in the central nervous system (CNS) as a. alpha-adrenergic blocking agents. b. alpha-adrenergic agonists. c. beta-adrenergic blocking agents. d. beta-blockers with alpha-blocking activity.

ANS: B

-Methyldopa and clonidine act in the CNS as -adrenergic agonists. Alpha-adrenergic blocking agents include doxazosin, prazosin, and terazosin. Beta-adrenergic blocking agents include atenolol, betaxolol, bisoprolol, metoprolol, nadolol, propranolol, and timolol. Beta-blockers with alpha-blocking activity include carvedilol and labetalol.

DIF: Comprehension REF: Hypertension (Treatment of Hypertension [Table 12.5: Mechanisms of Action of the Antihypertensive Agents]) | p. 137 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 77. Which antihypertensive agent is associated with a nonproductive cough? a. Angiotensin receptor blocker b. Beta-adrenergic blocking agent c. Alpha1-adrenergic blocking agent d. Angiotensin-converting enzyme inhibitor ANS: D

ACEIs produce nonproductive cough because of their ability to raise the levels of bradykinin. It occurs because blood levels of bradykinin rise when ACEIs block ACE, the enzyme that normally destroys bradykinin. Angiotensin receptor blockers (ARBs) do not alter the levels of bradykinin.

DIF: Recall REF: Hypertension (Diuretic Agents [Angiotensin-Converting Enzyme Inhibitors]) | p. 140 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 78. Which agent is contraindicated in pregnant women due to the risk of teratogenicity? a. Methyldopa b. Labetalol c. Captopril d. Nifedipine ANS: C

ACEIs should not be given to women who could be pregnant or could become pregnant due to the risk of teratogenicity. Methyldopa, labetalol, and nifedipine are frequently administered to pregnant women.

DIF: Comprehension REF: Hypertension (Diuretic Agents [Angiotensin-Converting Enzyme Inhibitors]) | p. 140 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 79. Each of the following is true for management of the dental patient taking warfarin except one. Which

is the exception? a. Use of aspirin should be avoided. b. Most dental procedures do not require a change in the dose of warfarin. c. Insure the patient is free of infection before scaling/root planning is performed. d. Ask the patient to stop taking warfarin 3 days before the procedure.

ANS: D

According to current recommendations it is not necessary to reduce or discontinue warfarin prior to dental therapy. Avoid aspirin and aspirin-containing compounds; acetaminophen and opioids may be used. Many surgical procedures can be carried out on a patient receiving therapeutic doses of anticoagulants. The patient should be free of infection before scaling and root planning is performed.

DIF: Comprehension REF: Drugs that Affect Blood Coagulation (Oral Anticoagulants [Warfarin]) | p. 157 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology 80. Which is true of American diagnosed with hypertension? a. Overall, women have a higher prevalence than men. b. Overall, men have a higher prevalence than women. c. Hispanics have the highest prevalence of hypertension. d. Non-Hispanic Asians have the highest prevalence of hypertension.

ANS: B

Overall, men have a higher prevalence than women (47% versus 43%). However, it is higher among women than men for those over 60 years of age (66.8% versus 58.5%). The age-adjusted prevalence of hypertension is 54% in non-Hispanic blacks, 46% in non-Hispanics whites, 39% in non-Hispanic Asians, and 36% in Hispanics.

DIF: Comprehension REF: Hypertension | p. 134 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 81. The percentage of Americans diagnosed with hypertension is which percentage? a. 5% b. 15% c. 25% d. 35% e. 45% ANS: E

Hypertension affects some 108 million Americans (45%) and more than 1.3 billion individuals worldwide.

DIF: Recall REF: Hypertension | p. 134 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

82. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a. 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors. b. antibodies. c. niacin. d. inhibitors of intestinal absorption of cholesterol. e. fibric acid derivatives.

ANS: B

These drugs are monoclonal antibodies that bind to and inactivate the PSCK9 protein, and increase the amount of LDL cholesterol that is metabolized by the liver. PCSK9 inhibitors are the newest class of drugs that have been shown to decrease LDL cholesterol by as much as 60%. Two PCSK9 inhibitors have been approved for use in the United States. They are alirocumab (Praluent) and evolocumab (Repatha).

DIF: Recall OBJ: 8

REF: Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors | p. 155 TOP: NBDHE, 6.0. Pharmacology

83. How is low-molecular-weight heparin (LMWH) administered? a. Orally b. Subcutaneously c. Intravenously d. Intramuscularly ANS: B

The two LMWHs are enoxaparin (Lovenox) and dalteparin (Fragmin) and they are administered subcutaneously. Heparin must be given by injection and cannot be used orally. Newer heparins are being used, but until an oral dose form is developed, their use will be limited.

DIF: Recall REF: Drugs that Affect Blood Coagulation (Low-Molecular-Weight Heparin) | p. 155 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 84. Which drug is a platelet aggregation inhibitor that has largely replaced ticlopidine? a. Edoxaban (Savaysa) b. Dabigatran (Pradaxa) c. Clopidogrel (Plavix) d. Streptokinase (Streptase) e. Ticagrelor (Brilinta) ANS: E

Ticagrelor (Brilinta) is a platelet aggregation inhibitor. It is used in conjunction with aspirin for the prevention of myocardial infarction and stroke in persons with acute coronary syndrome. The most common side effects include shortness of breath and bleeding. Edoxaban (Savaysa) is a factor Xa inhibitor. Dabigatran (Pradaxa) is a direct thrombin inhibitor. Clopidogrel (Plavix) is an inhibitor of adenosine diphosphate (ADP)-induced platelet aggregation. Streptokinase (Streptase) promotes the conversion of plasminogen to plasmin.

DIF: Application OBJ: 10

REF: Thienopyridines (Ticagrelor) | p. 158 TOP: NBDHE, 6.0. Pharmacology

MULTIPLE RESPONSE 1. The most current recommendations by the American Heart Association are a blood pressure goal of

less than a. 120/80 b. 130/80 c. 140/90 d. 150/90

mm Hg for all people with diagnosed hypertension. (Select all that apply.)

ANS: B

The most current recommendation by the American Heart Association is a blood pressure goal of less than 130/80 mm Hg for all people with diagnosed hypertension regardless of age or presence or absence of chronic kidney disease or diabetes.

DIF: Recall REF: Hypertension | p. 134 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

2. Which is true regarding the use of a local anesthetic with vasoconstrictor for a patient with

cardiovascular disease? (Select all that apply.) a. Cardiovascular patients should not receive epinephrine. b. Injecting slowly will reduce the incidence of adverse reactions from the vasoconstrictor. c. An intravascular injection will reduce the incidence of adverse reactions from the vasoconstrictor. d. Poor management of pain can cause the release of endogenous epinephrine.

ANS: B, D

Using a slow rate of injection and appropriate aspiration techniques to avoid intravascular injection reduces the chances of vasoconstrictor adverse reactions. Patient anxiety can cause the release of endogenous epinephrine. Cardiovascular patients should receive epinephrine. The majority of cardiovascular patients should benefit from the use of epinephrine in the local anesthetic agent. An intravascular injection triggers the “fight-or-or flight” reaction, which increases the pulse rate and blood pressure.

DIF: Comprehension REF: Dental Implications of Cardiovascular Disease (Vasoconstrictor Limit) | p. 134 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. Entresto works primarily by (Select all that apply.) a. stimulating diuresis. b. blocking angiotensin receptors. c. blocking calcium channels. d. inhibiting neprilysin.

ANS: B, D

The drug works by inhibiting neprilysin and blocking angiotensin II type-1 receptors, which increases the levels of peptides that are broken down by neprilysin, thereby lowering blood pressure. Entresto is not a diuretic or calcium channel blocker. It is the first of a new class of drugs that combines sacubitril (neprilysin inhibitor) and valsartan (ARB).

DIF: Comprehension REF: Angiotensin II Receptor Neprilysin Inhibitor | p. 145 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

4. Which of the following is true regarding digitalis glycosides (digoxin, Lanoxin, Digitek)? (Select all

that apply.) a. Can reduce pulmonary edema b. Increase contractility of the heart c. Have a narrow therapeutic index d. Are considered a first-line therapy for the treatment of heart failure (HF) e. Cause diuresis due to a direct effect on the kidneys ANS: A, B, C

Digitalis glycosides increase the efficiency of the heart’s contractions. Improved pumping action allows more circulation to the kidneys, which reduces edema. The drug does have a narrow therapeutic index. Digoxin is no longer considered as first-line therapy. It is now only used in selected patients with stage C HF with reduced left ventricular ejection fraction (LVEF). The diuresis is not a result of an effect on the kidneys; it is a result of digoxin’s indirect effect produced by the improving heart’s function.

DIF: Application REF: Cardiac Glycosides (Digitalis Glycosides [Pharmacologic Effects]) | p. 147 | Cardiac Glycosides (Digitalis Glycosides [Adverse Reactions]) | p. 147 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 5. Diuretics can produce

, which can predispose a patient to serious arrhythmias. (Select all that

apply.) a. hyperkalemia b. hypokalemia c. hyperuricemia d. hypouricemia ANS: B, C

Potassium depletion can result from metabolic changes that occur in diabetic acidosis, in prolonged vomiting or diarrhea, and in the debilitation caused by surgery. Prolonged administration of diuretics can produce hypokalemia, which can predispose a patient to serious arrhythmias. Digitalis is used to treat arrhythmias, and its toxicity can produce arrhythmias. Hyperuricemia is of special concern when the person has gout. In the patient with diabetes, hyperglycemia, or impaired glucose tolerance, it must be managed by diet or insulin alterations. There is a small chance of cross-hypersensitivity between the sulfonamide oral medicine and the thiazide diuretics due to the similarity in their structures. The most common oral adverse reaction is xerostomia. Diuretics can cause a loss of electrolytes such as potassium. Hyperkalemia is an excess of potassium ions and hypokalemia is a deficit. Uric acid is created during the breakdown of purines. Hyperuricemia and urate crystals may be found in joints and tissues of a person with gout.

DIF: Comprehension REF: Hypertension (Diuretic Agents [Thiazide Diuretics]) | p. 139 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. Which of the following antibiotics can increase the toxicity of digoxin in some patients? (Select all

that apply.) a. Penicillin b. Erythromycin c. Tetracycline d. Metronidazole e. Ampicillin ANS: B, C

Erythromycin and tetracycline can increase the toxicity of digoxin in some patients. The remaining choices are not associated with increased toxicity when administered along with digoxin.

DIF: Comprehension REF: Cardiac Glycosides (Digitalis Glycosides [Dental Drug Interactions]) | p. 147 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 7. Calcium channel blockers may be used to treat which of the following? (Select all that apply.) a. Angina b. Cardiac arrhythmia c. Hypertension d. Hyperlipidemia ANS: A, B, C

Calcium channel blockers may be used for the treatment of angina, cardiac arrhythmias, and hypertension. Adverse effects include dizziness, weakness, constipation, and hypotension.

Hyperlipidemia is treated with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, bile acidbinding resins, niacin, and/or gemfibrozil.

DIF: Comprehension REF: Hypertension (Calcium Channel Blocking Agents) | p. 141 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. What precautions should the dental professional exercise with a patient taking an alpha-adrenergic

receptor blocker? (Select all that apply.) a. Raise and lower the dental chair slowly. b. Use local anesthetic with no or low-dose epinephrine. c. Use caution and local measures for excessive bleeding tendency. d. Nonsteroidal antiinflammatory drugs (NSAIDs) will exacerbate the antihypertensive effect of the 1-blockers to produce a hypertensive crisis.

ANS: A, B, C

-Adrenergic blockers can cause postural or orthostatic hypotension, so the dental chair must be moved slowly to prevent syncope. They antagonize the vasoconstrictive actions of epinephrine.

Because vasoconstrictors are contraindicated, caution and local measures are needed to manage excessive bleeding. NSAIDS, especially indomethacin, can reduce the antihypertensive effect of the 1-blockers. They produce this effect by inhibiting renal prostaglandin synthesis or causing sodium and fluid retention.

DIF: Application REF: Hypertension (Alpha1-Adrenergic Blocking Agents [Adverse Reactions]) | p. 143 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Which of the following are true of both apixaban (Eliquis) and rivaroxaban (Xarelto)? (Select all that

apply.) a. Both are indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. b. Both are indicated for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). c. Both drugs have a marked treatment benefit when contrasted with warfarin. d. INR monitoring is not required with these drugs.

ANS: A, D

Both drugs are indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Unlike warfarin, these drugs do not have an antidote. Also, monitoring is not required. Rivaroxaban is also indicated for the treatment of deep vein thrombosis and pulmonary embolism and for the reduction in the risk of recurrence of DVT and PE. A systematic review of the literature has demonstrated that the treatment benefits with these drugs compared to warfarin are small and vary on the control achieved by warfarin therapy. Patients already taking warfarin with excellent INR numbers may have little to gain by switching to the newer agent.

DIF: Comprehension REF: Drugs that Affect Blood Coagulation (Factor Xa Inhibitors) | p. 157 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Myocardial infarction occurring 9 months prior to an office visit would be a contraindication to dental

treatment.

ANS: F

Dental treatment can be given to a patient 6 months after a myocardial infarction.

DIF: Recall REF: Dental Implications of Cardiovascular Disease (Contraindications to Treatment) | p. 133 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Some studies have found that the presence of periodontal disease predicts an increase in morbidity and

mortality resulting from cardiovascular disease and others have failed to show a relationship.

ANS: T

Several studies correlate the patient’s periodontal condition to cardiovascular disease over time.

DIF: Recall REF: Dental Implications of Cardiovascular Disease (Periodontal Disease and Cardiovascular Disease) | p. 134 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. Blood returning from the pulmonary circulation enters the left atrium.

ANS: T

Blood goes from the peripheral circulation to the right atrium, to the right ventricle, to the lungs for oxygenation, to the left atrium, to the left ventricle, and is then pumped at high pressure into the arteries. If the left side of the heart fails, the blood backs up into the pulmonary circulation (lungs).

DIF: Recall REF: Heart Failure | p. 145 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

4. Angiotensin-converting enzyme inhibitors (ACEIs) are a treatment of choice for congestive heart

failure (CHF).

ANS: T

The most current guidelines from the ACC and the AHA recommend prescribing an ACEI for patients with symptomatic (stage C) HF and for asymptomatic patients with HFrEF of 35% or a history of MI unless there are contraindications to an ACEI. DIF: Recall REF: Angiotensin II Receptor Neprilysin Inhibitor (Angiotensin-Converting Enzyme Inhibitors) | p. 145 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 5. Preload refers to blood in the arteries, and afterload refers to blood in the veins.

ANS: F

Preload refers to the blood that is coming to the heart from the general circulation (i.e., from the veins).

Afterload refers to the resistance that the heart needs to work against (i.e., from the arteries, “downstream” from the heart).

DIF: Recall REF: Antianginal Drugs (Nitroglycerin-Like Compounds [Mechanism]) | p. 148 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 6. One can prevent an attack of angina pectoris by administering nitrous oxide.

ANS: T

Nitrous oxide can reduce anxiety, which is commonly a precipitating factor in angina pectoris. Nitrous oxide also produces vasodilation.

DIF: Recall REF: Antianginal Drugs (Dental Implications [Prevention of Anginal Attack]) | p. 151 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 7. -Methyldopa and clonidine act in the central nervous system (CNS) as -adrenergic antagonists.

ANS: F

-Methyldopa and clonidine act in the CNS as -adrenergic agonists.

DIF: Recall REF: Hypertension (Treatment of Hypertension [Table 12.5: Mechanisms of Action of the Antihypertensive Agents]) | p. 137 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. A key side effect that angiotensin-converting enzyme inhibitors (ACEIs) have that angiotensin

receptor blockers do not have is nonproductive cough.

ANS: T

ACEIs produce nonproductive cough because of their ability to raise the levels of bradykinin.

Angiotensin receptors blockers (ARBs) do not alter the levels of bradykinin.

DIF: Recall REF: Hypertension (Diuretic Agents [Angiotensin-Converting Enzyme Inhibitors]) | p. 140 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Statins are contraindicated as an antihyperlipidemic therapy in pregnant women.

ANS: T

The use of statins is contraindicated in women who are pregnant or nursing.

DIF: Recall REF: Antihyperlipidemic Agents (3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors) | p. 152 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 10. Most dental procedures do not require a change in the dose of warfarin.

ANS: T

Many surgical procedures can be carried out on a patient receiving therapeutic doses of anticoagulants.

DIF: Recall REF: Drugs that Affect Blood Coagulation (Oral Anticoagulants [Warfarin]) | p. 157 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology

Chapter 13: Drugs for the Treatment of Gastrointestinal Disorders Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which of the following is the most common gastrointestinal disease in the United States population? a. Peptic ulcers b. Gastroesophageal reflux disease (GERD) c. Diarrhea d. Constipation e. Ulcerative colitis ANS: B

GERD is the prevalent gastrointestinal disease in the United States. In this condition, the stomach contents, including the acid, reflux, or flow backward through the cardiac sphincter, up into the esophagus. Ulcers may occur in the stomach or the small intestine. Diarrhea is treated with antidiarrheals and laxatives are used for constipation. An autoimmune response is thought to be associated with ulcerative colitis.

DIF: Recall REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Gastroesophageal Reflux Disease]) | p. 160 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following is the main problem causing gastroesophageal reflux disease (GERD)? a. Excess stomach acid b. A diet that is too high in saturated fat c. Lack of adequate function of the cardiac sphincter d. Being overweight ANS: C

The main problem is the lack of adequate function of the cardiac sphincter, allowing backflow to occur. The symptoms are exacerbated by eating large meals and by assuming a supine position. In this condition, the stomach contents flow up into the esophagus. Because the esophagus is not designed to endure the stomach’s acid irritation, inflammation and erosion can occur.

DIF: Recall REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Gastroesophageal Reflux Disease]) | p. 160 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. If a dentist notices a great amount of enamel erosion during a clinical examination, the patient should

be referred to his or her primary care physician for evaluation of which of the following? a. Duodenal ulcers b. Peptic ulcers c. Gastroesophageal reflux disease (GERD) d. Crohn disease ANS: C

A patient who presents with symptoms of enamel erosion should be referred to his or her primary care physician for further evaluation. It could be due to GERD. Ulcers and Crohn disease will not cause enamel erosion.

DIF: Application REF: Gastrointestinal Drugs (Dental Implications [Box 13.1: Management of Dental Patients With Peptic Ulcer Disease or Gastroesophageal Reflux Disease]) | p. 161 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. Which of the following is a serious possible consequence of gastroesophageal reflux disease (GERD)? a. Crohn disease b. Barrett esophagus c. Ulcerative colitis d. Gastrointestinal stasis ANS: B

Barrett esophagus occurs when the cells of the lower esophagus become damaged as a result of repeated exposure to stomach acid. Barrett esophagus is most often diagnosed in patients with longterm GERD; however, only a small percentage of patients with GERD will go on to develop Barrett esophagus. Ulcerative colitis and Crohn disease are subcategories of chronic inflammatory bowel disease. Barrett esophagus is not associated with intestinal stasis.

DIF: Comprehension REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Gastroesophageal Reflux Disease]) | p. 160 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Which is the primary concern for a patient diagnosed with Barrett esophagus? a. Inability to eat spicy food b. Excessive burping and indigestion c. Esophageal cancer d. Ulcerative colitis ANS: C

Barrett esophagus is normally diagnosed with endoscopy. Barrett esophagus is of concern because a small number of patients can progress to esophageal cancer. Repeated exposure to stomach acid causes a change in the color and composition of esophageal cells. This can lead to a hiatal hernia; however, this is not the most serious potential consequence of having Barrett esophagus.

DIF: Recall REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Gastroesophageal Reflux Disease]) | p. 160 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 6. Which of the following is the best non-narcotic analgesic for the management of a dental patient with

peptic ulcer disease or gastroesophageal reflux disease? a. Acetaminophen b. Aspirin c. Nonsteroidal antiinflammatory (NSAID) d. Tylenol #3 ANS: A

Acetaminophen is the best choice. Avoid the use of aspirin or NSAIDs because they can exacerbate an existing ulcer and further aggravate GERD. Tylenol #3 contains codeine, a centrally acting opioid rather than a peripheral drug.

DIF: Application REF: Gastrointestinal Drugs (Dental Implications [Box 13.1: Management of Dental Patients With Peptic Ulcer Disease or Gastroesophageal Reflux Disease]) | p. 161 | Dental Hygiene Considerations | p. 166 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 7. Which of the following agents is a synthetic prostaglandin indicated for NSAID-induced ulcers? a. Ranitidine b. Misoprostol c. Omeprazole d. Metoclopramide ANS: B

NSAIDs inhibit PG synthesis, and PGs have a protective effect on the stomach lining. Misoprostol is a PGE2 and can replenish the PG in the stomach. It increases gastric mucus and inhibits gastric acid secretion. Ranitidine (Zantac) is an H2-receptor blocker. Omeprazole/sodium bicarbonate (Zegerid) is a proton-pump inhibitor. Both H2–blockers and PPIs reduce the symptoms of NSAID-induced ulcers but do not prevent the ulcers. Metoclopramide (Reglan) is a dopamine antagonist. It is indicated for relief of symptoms associated with diabetic gastroparesis and improves delayed gastric emptying time.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Miscellaneous Gastrointestinal Drugs [Misoprostol]) | p.

163 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 8. Sucralfate can be thought of as a “bandage” for ulcers because it inhibits the action of pepsin and

absorbs the bile salts. a. Both parts of the statement and the reason are correct and related. b. Both parts of the statement and the reason are correct, but not related. c. Both parts of the statement are correct, but the reason is not. d. Both parts of the statement are not correct, but the reason is correct. e. Neither the statement nor the reason is correct.

ANS: B

Sucralfate can be thought of as a “bandage” for ulcers because it combines with proteins, forming a complex that binds preferentially with the ulcer site. Sucralfate also inhibits the action of pepsin and absorbs the bile salts. However, the physical form sucralfate takes and the physical protection it provides the ulcer site make it akin to a bandage. All other choices are incorrect.

DIF: Application REF: Drugs Used to Treat Gastrointestinal Diseases (Miscellaneous Gastrointestinal Drugs [Sucralfate]) | p.

163 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 9. The following are actions of metoclopramide except one. Which is the exception? a. Decreases peristalsis by acting directly on smooth muscle of the gastrointestinal

tract b. Blocks the action of dopamine c. Accelerates gastric emptying time d. Increases the tone of the lower esophageal sphincter ANS: A

Metoclopramide stimulates motility of the upper gastrointestinal tract and increases peristalsis in the duodenum. Metoclopramide is a dopamine antagonist that facilitates cholinergic effects in the gastrointestinal tract. Metoclopramide stimulates the motility of the upper gastrointestinal tract. It increases the tone of the lower esophageal sphincter.

DIF: Comprehension REF: Drugs Used to Treat Gastrointestinal Diseases (Miscellaneous Gastrointestinal Drugs [Metoclopramide]) | p. 163 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 10. Which histamine-2 (H2)-blocking agent has been associated with dry mouth and taste alterations? a. Cimetidine (Tagamet) b. Ranitidine (Zantac) c. Famotidine (Pepcid)

d. Meclizine (Bonine) ANS: C

Famotidine has been associated with dry mouth and taste alterations. Cimetidine and ranitidine are H 2blockers that do not cause xerostomia or taste alterations. Meclizine does cause xerostomia, but is an anticholinergic rather than H2-blocker. It is used to prevent vomiting, vertigo, and motion sickness.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Histamine2–Blocking Agents [Adverse Reactions]) | p.

161 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 11. Which of the following adverse reactions is common to all of the currently marketed H2-blocking

agents? a. Abnormal liver function tests b. Thrombocytopenia c. Slurred speech d. Gynecomastia ANS: A

Reversible hepatitis and abnormal liver function tests have been reported with all H 2-blockers.

Cimetidine’s hematologic effects include granulocytopenia, thrombocytopenia, and neutropenia.

Slurred speech, delusions, confusion, and headache are associated with cimetidine. Because cimetidine binds with the androgen receptors, it produces antiandrogenic effects such as gynecomastia, reduction in sperm count, and sexual dysfunction. Neither ranitidine nor famotidine has been found to possess antiandrogenic activity.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Histamine2–Blocking Agents [Adverse Reactions]) | p.

161 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 12. Which agent inhibits the hydrogen/potassium adenosine triphosphate (H +/K+ ATPase) enzyme system

found at the surface of the gastric parietal cell? a. Ketoconazole b. Lansoprazole c. Misoprostol d. Famotidine e. Metronidazole ANS: B

Proton-pump inhibitors, such as lansoprazole, inhibit gastric H+/K+ ATPase as their mechanism of action. Ketoconazole is an antifungal agent. Misoprostol is prostaglandin E 2-alpha PGE2. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibacterial agent.

DIF: Recall REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Gastroesophageal Reflux Disease]) | p. 160 | Drugs Used to Treat Gastrointestinal Diseases (Proton Pump Inhibitors) | p. 162 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. Newer types of combination therapy for treating ulcers often combine an antibiotic with a(n) a. hyperosmotic laxative.

b. proton-pump inhibitor. c. antacid. d. prostaglandin.

ANS: B

Newer combinations often use one antibiotic and a PPI such as clarithromycin and esomeprazole (Nexium). These agents are used for 2 weeks and often result in a cure. There are several types of regimens for treating ulcers caused by Helicobacter pylori. A combination of two antiinfective agents, an H2-blocker or a PPI, and bismuth subsalicylate (Pepto-Bismol) may be used.

DIF: Comprehension REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Ulcers]) | p. 161 | Drugs Used to Treat Gastrointestinal Diseases (Mixed Antiinfective Therapy for Ulcer Treatment) | p. 162 OBJ: 1 | 2 TOP: NBDHE, 6.0. Pharmacology 14. Magnesium sulfate should be used with caution in patients with renal impairment because

hypermagnesemia has been reported in patients with renal disease. a. Both the statement and the reason are correct and related. b. Both the statement and the reason are correct, but not related. c. The statement is correct, but the reason is not. d. The statement is not correct, but the reason is correct. e. Neither the statement nor the reason is correct.

ANS: A

Magnesium salts produce osmotic diarrhea. Magnesium from magnesium sulfate may be absorbed into the body. This magnesium will not be properly excreted through the kidney from patients with renal impairment, and the level of magnesium in the body may become abnormally high.

DIF: Comprehension REF: Drugs Used to Treat Gastrointestinal Diseases (Antacids) | pp. 162-163 | Drugs Used to Treat Gastrointestinal Diseases (Laxatives and Antidiarrheals [Laxatives]) | p. 164 OBJ: 2 | 4 TOP: NBDHE, 6.0. Pharmacology 15. Certain gastrointestinal drugs such as have been abused by patients with a. antiemetics; low blood sugar b. laxatives; bulimia c. nitroglycerin; familial hypercholesterolemia d. antispasmodics; diabetes

.

ANS: B

Some patients with bulimia misuse laxatives to induce bowel movements. Short-term, occasional use for constipation and prior to diagnostic procedures such as colonoscopy or barium enema are legitimate indications. For other patients, no connection has been established among the drug, the disease, and abuse.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Laxatives and Antidiarrheals [Laxatives]) | p. 163OBJ: 4 TOP: NBDHE, 6.0. Pharmacology

16. Use of which laxative is able to interfere with the absorption of the fat-soluble vitamins (A, D, E, and

K)? a. b. c. d.

Bisacodyl Dioctyl sodium sulfosuccinate Mineral oil Magnesium sulfate

ANS: C

Because mineral oil is a hydrophobic oil, fat-soluble vitamins can dissolve in it, and their absorption into the body will be impeded. The other choices are all laxatives, but they do not interfere with the absorption of fat-soluble vitamins.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Laxatives and Antidiarrheals [Laxatives]) | p. 163OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 17. Which of the following gastrointestinal drugs is a phenothiazine used to treat nausea? a. Mineral oil b. Loperamide c. Lansoprazole d. Prochlorperazine e. Ranitidine ANS: D

Prochlorperazine (Compazine) is used to treat severe nausea. Mineral oil is a lubricant that is used to treat constipation. Loperamide is used to treat diarrhea. Lansoprazole is used to treat ulcers and GERD. Ranitidine is used to treat ulcers and GERD. DIF: Recall OBJ: 6

REF: Drugs Used to Treat Gastrointestinal Diseases (Phenothiazines) | p. 164 TOP: NBDHE, 6.0. Pharmacology

18. Which type of drugs work by blocking 5-HT3 receptors in the central nervous system and the

chemoreceptor trigger zone? a. Laxatives b. Antidiarrheals c. Antiemetics d. Antacids e. Proton-pump inhibitors ANS: C

Ondansetron (Zofran), dolasetron (Anzemet), granisetron (Kytril), and palonosetron (Aloxil) control the nausea and vomiting of postoperative and cancer chemotherapeutic agents. The most common adverse effects include constipation or diarrhea, headache, and dizziness. Laxatives include: bulk laxatives, lubricants, stimulants, stool softeners, and osmotics. Antidiarrheals include: opioid-like agents and adsorbents. Antacids are drugs that partially neutralize hydrochloric acid in the stomach.

Proton-pump inhibitors affect the hydrogen/potassium adenosine triphosphate enzyme system at the surface of the gastric parietal cell.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Antiemetics) | p. 164 | Drugs Used to Treat

Gastrointestinal Diseases (5-HT3 Receptor Antagonists) | p. 165 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 19. Which of the following types of drugs is considered first-line therapy for treatment of irritable bowel

syndrome (IBD)? a. Antibiotic b. Antacid c. Antidiarrheal d. Antiinflammatory ANS: D

Antiinflammatory drugs are usually the first line of therapy in the treatment of IBD. These drugs include sulfasalazine (Azulfidine), mesalamine (Apriso), balsalazide (Colazal), and olsalazine (Dipentum) and work by reducing the symptoms of IBD by decreasing inflammation.

Immunosuppressant drugs, such as 6-mercaptopurine (Purinethol) and azathioprine (Imuran), work by blocking the immune reaction that contributes to inflammation. Non-aspirin salicylates, adrenocorticosteroids, immune modifiers, and antibiotics are used to treat IBD; however, they are not first-line therapy. Acute gastritis and symptoms of ulcers are sometimes managed with antacids.

DIF: Comprehension REF: Drugs Used to Treat Gastrointestinal Diseases (Agents Used to Manage Chronic Inflammatory Bowel Disease) | p. 165 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 20. A patient with gastroesophageal reflux disease (GERD) may not be able to sit in a supine position in

the dental chair due to a. ulcerative colitis. b. Crohn disease. c. acid reflux. d. irritable bowel syndrome (IBS).

ANS: C

Acid reflux may prevent the patient from sitting in a supine position. Some patients may not be able to sleep while lying down and may be to raise the head of the bed with bricks or use several pillows.

Ulcerative colitis, Crohn disease, and irritable bowel syndrome all involve the lower gastrointestinal tract.

DIF: Comprehension REF: Gastrointestinal Drugs (Dental Implications [Box 13.1: Management of Dental Patients With Peptic Ulcer Disease or Gastroesophageal Reflux Disease]) | p. 161 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 21. Each of the following is part of common multidrug regimens for treatment of ulcers due to

Helicobacter pylori except one. Which is the exception? a. Bismuth subsalicylate (Pepto-Bismol) b. Metronidazole c. Amoxicillin d. Tetracycline e. Sodium bicarbonate ANS: E

Ulcers are closely related to Helicobacter pylori and are treated with antibiotics. Triple therapy consists of clarithromycin + amoxicillin or metronidazole + a proton-pump inhibitor. Quadruple therapy consists of bismuth subsalicylate (Pepto-Bismol) + metronidazole + tetracycline + a protonpump inhibitor or H2-blocker. Antacids such as sodium bicarbonate, magnesium hydrochloride, aluminum hydroxide, or calcium carbonate are not part of either triple therapy or quadruple therapy for Helicobacter pylori.

DIF: Comprehension REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Ulcers]) | pp. 160-161 | Drugs Used to Treat Gastrointestinal Diseases (Mixed Anti-infective Therapy for Ulcer Treatment [Table 13.2: Common Multidrug Regimens for Helicobacter pylori]) | p. 162 OBJ: 1 | 2 TOP: NBDHE, 6.0. Pharmacology 22. Proton-pump inhibitors (PPIs) carry a greater risk of diarrhea associated with a. Helicobacter pylori. b. Clostridium difficile. c. Escherichia coli. d. Aggregatibacter actinomycetemcomitans.

ANS: B

PPIs are associated with a greater risk of Clostridium difficile–associated diarrhea. Helicobacter pylori is associated with ulcers in the upper gastrointestinal tract. E. coli is a normal inhabitant of the intestinal tract. A. actinomycetemcomitans is a putative periodontal pathogen.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Proton Pump Inhibitors [Adverse Reactions]) | p. 162 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 23. Which type of laxative is considered best to use? a. Bulk laxatives b. Lubricants c. Stimulants d. Stool softeners e. Osmotic laxatives ANS: A

They are the safest and act most like the normal physiology of humans. Patients who have problems with constipation can increase their intake of fiber or use any bulk laxative without problems.

Lubricants are no longer recommended as they can interfere with absorption of fat-soluble vitamins.

Stimulants can lead to intestinal cramping. The use of stool softeners should be limited to short-term use. Osmotics hold water and should be used with caution in patients who have renal impairment.

DIF: Comprehension REF: Drugs Used to Treat Gastrointestinal Diseases (Laxatives and Antidiarrheals [Laxatives]) | p. 163OBJ: 4 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Stomach or small intestine ulcers may be due to (Select all that apply.)

a. b. c. d.

excess stomach acid from worrying. an infection. long-term use of nonsteroidal antiinflammatory drugs (NSAIDs). spicy or hot foods.

ANS: B, C

Most ulcers are related to the presence of Helicobacter pylori. Many ulcers can now be cured by using a combination of one or more antibiotics and an H2-blocker or a proton-pump inhibitor (PPI) to reduce stomach acid. Some ulcers, especially in the elderly, are secondary to the long-term use of NSAIDs. In the past, it was thought that ulcers were caused by too much stomach acid from worrying. Ulcers are not a consequence of eating spicy or hot food.

DIF: Comprehension REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Ulcers]) | pp. 160-161 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Crohn disease (Select all that apply.) a. extends through all layers of the intestinal wall. b. involves only the mucosa of the intestinal wall. c. can involve the entire intestine. d. does not involve the small intestine.

ANS: A, C

Crohn disease extends through all layers of the wall of the intestine. Crohn disease can involve the entire intestine; however, the colon is most likely affected. Ulcerative colitis involves only the mucosa of the intestine. Ulcerative colitis involves the rectum and may involve the distal portion of the colon, but does not involve the small intestine.

DIF: Comprehension REF: Drugs Used to Treat Gastrointestinal Diseases (Agents Used to Manage Chronic Inflammatory Bowel Disease) | p. 165 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 3. Which of the following categories of drugs are used to treat diarrhea? (Select all that apply.) a. Adsorbents b. Proton-pump inhibitor (PPI) c. Opioid-like agents d. Phenothiazine e. Adrenocorticosteroid ANS: A, C

The most common adsorbent combination used to treat diarrhea is kaolin and pectin (Kaopectate). The opioids, such as diphenoxylate with atropine (Lomotil) and Loperamide (OTC Imodium), are the most effective antidiarrheal agents. They decrease peristalsis by acting directly on the smooth muscle of the gastrointestinal tract. Proton-pump inhibitors are inhibitors of gastric acid secretion. They are effective in combination with antibiotics in healing duodenal ulcers, and as monotherapy for the acute treatment and maintenance therapy of GERD. Phenothiazines can be used as antiemetics. Adrenocorticosteroids may be used in the treatment of irritable bowel syndrome (IBD).

DIF: Comprehension REF: Drugs Used to Treat Gastrointestinal Diseases (Laxatives and Antidiarrheals [Antidiarrheals]) | p. 164

OBJ:

5

TOP:

NBDHE, 6.0. Pharmacology

TRUE/FALSE 1. Most ulcers are due to excess stomach acid from worrying.

ANS: F

Most ulcers are related to the presence of Helicobacter pylori. Many ulcers can now be cured by using a combination of one or more antibiotics and an H 2-blocker or a proton-pump inhibitor (PPI) to reduce stomach acid.

DIF: Recall OBJ: 1

REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Ulcers]) | pp. 160-161 TOP: NBDHE, 6.0. Pharmacology

2. A patient with GERD may not be able to sit in a supine position in the dental chair.

ANS: T

Acid reflux may prevent the patient from sitting in a supine position. Some patients may not be able to sleep while lying down and may be to raise the head of the bed with bricks or use several pillows.

DIF: Recall REF: Gastrointestinal Drugs (Dental Implications [Box 13.1: Management of Dental Patients With Peptic Ulcer Disease or Gastroesophageal Reflux Disease]) | p. 161 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. Antacids are the best treatment for peptic ulcers.

ANS: F

Acute gastritis and symptoms of ulcers are sometimes managed with antacids; however, ulcers are closely related to Helicobacter pylori and are treated with antibiotics.

DIF: Recall REF: Gastrointestinal Drugs (Gastrointestinal Diseases [Ulcers]) | pp. 160-161 | Drugs Used to Treat Gastrointestinal Diseases (Antacids) | p. 162 OBJ: 1|2 TOP: NBDHE, 6.0. Pharmacology 4. Proton-pump inhibitors (PPIs) may be associated with a greater risk of Clostridium difficile–associated

diarrhea.

ANS: T

Some of the most frequent side effects associated with PPIs include headache, diarrhea, abdominal pain, nausea, and dizziness. Additionally, they are associated with a greater risk of Clostridium difficile–associated diarrhea.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Proton Pump Inhibitors [Adverse Reactions]) | p. 162 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 5. Bismuth subsalicylate (Pepto-Bismol) may be useful in treating ulcers.

ANS: T

Pepto-Bismol is thought to have some antiinfective properties.

DIF: Recall REF: Drugs Used to Treat Gastrointestinal Diseases (Mixed Antiinfective Therapy for Ulcer Treatment) | p.

162 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

Chapter 14: Drugs for the Treatment of Seizure Disorders Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which of the following statements is true concerning epilepsy? a. Epileptic seizures can be recorded on electrocardiogram. b. Seizure activities are estimated to affect approximately 10% of the population. c. The majority of epileptic patients have idiopathic epilepsy. d. The most common generalized seizures are temporal lobe (psychomotor).

ANS: C

The majority of epileptic patients have idiopathic epilepsy, meaning an unknown cause. Epileptic seizures are recorded on an electroencephalogram (EEG) rather than electrocardiogram. Seizure disorders are estimated to affect 1% of the population; therefore, the dental team will likely encounter a patient with epilepsy. Temporal lobe seizures are partial rather than generalized seizures.

DIF: Comprehension REF: Epilepsy | p. 167 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following seizures are categorized as generalized seizures? a. Absence seizures b. Simple (Jacksonian) seizures c. Tonic-clonic seizures d. Both A and C e. Both B and C ANS: D

Absence seizures and tonic-clonic seizures are considered to be generalized seizures. Consciousness is lost in both types. Whereas little movement occurs in absence seizures, major movement of large muscle groups occurs in tonic-clonic seizures. Simple (Jacksonian) seizures are considered partial seizures. Partial epilepsies involve activation of only part of the brain, and the location of the activity determines the clinical manifestation. The attack is called a simple partial attack when consciousness is not impaired. The attack is called a complex partial attack when consciousness is impaired.

DIF: Recall OBJ: 1

REF: Epilepsy (Generalized Seizures) | p. 167 TOP: NBDHE, 6.0. Pharmacology

3. Each of the following statements is true of absence seizures except one. Which is the exception? a. Seizures last a few seconds. b. No loss of body tone occurs. c. The patient is usually unaware that the seizure is happening. d. A drug of choice for treatment is ethosuximide.

e. To avoid trauma, tongue blades should not be used in the oral cavity.

ANS: E

Unlike tonic-clonic seizures, no uncontrolled motor activity occurs in absence seizures. Consequently, no risk exists in using tongue blades in these patients. The other choices are accurate characteristics of absence seizures. The symptoms include a brief loss of consciousness. Body tone is not lost and the patient is usually unaware the seizures are occurring. The drug of choice is either ethosuximide or valproate. Lamotrigine is an effective alternative.

DIF: Application OBJ: 1

REF: Epilepsy (Generalized Seizures [Absence Seizures]) | p. 167 TOP: NBDHE, 6.0. Pharmacology

4. Which of the following statements is true of absence seizures and tonic-clonic seizures? a. Both types of seizures involve the loss of consciousness. b. Consciousness returns gradually after an absence seizure, which is a major

problem for the dental team. c. Tonic-clonic seizures are not treated with medication. d. Both A and B are true. e. Both B and C are true.

ANS: A

The symptoms of absence seizures include a brief loss of consciousness with characteristic EEG waves and little movement. Generalized tonic-clonic seizures include longer periods of loss of consciousness and major motor activity of large muscles. Management of absence seizures poses no problems for the dental team. The team’s main concern is the adverse reactions that can occur from long-term administration of the drugs used to treat the disease. Tonic-clonic seizures are treated with medication.

Valproate, lamotrigine, and levetiracetam are considered the drugs of choice for treating generalized tonic-clonic seizures.

DIF: Application REF: Epilepsy (Generalized Seizures [Absence Seizures]) | p. 167 | Epilepsy (Generalized Seizures [TonicClonic Seizures]) | p. 167 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Seizures characterized by a duration for longer than 30 minutes are called _ a. akinetic b. complex c. status epilepticus d. myoclonic e. simple (Jacksonian)

seizures.

ANS: C

Status epilepticus seizures are an emergency situation, especially if hypoxia has occurred. Parenteral benzodiazepines, such as diazepam (Valium), are the drugs of choice to control this type of seizure.

Tonic-clonic, myoclonic, akinetic, and absence seizures are not defined as seizures of long duration.

Status epilepticus seizures are continuous tonic-clonic seizures that last longer than 30 minutes or recur before the end of the postictal period of the previous seizure.

DIF: Recall OBJ: 1

REF: Epilepsy (Generalized Seizures [Status Epilepticus]) | p. 168 TOP: NBDHE, 6.0. Pharmacology

6. Which of the following statements is true regarding adverse reactions to antiepileptic agents? a. These medications have a broad therapeutic index. b. CNS depression is a common side effect of antiepileptic agents. c. Central nervous system (CNS) depression will antagonize that of other sedative

agents. d. Both A and B are true. e. Both B and C are true.

ANS: B

Tolerance develops to the CNS effects while the antiepileptic effect persists. Impaired learning and cognitive abilities occur in some patients. Another CNS side effect is exacerbation of a seizure type that is not being treated. The antiepileptics have a narrow therapeutic index; therefore, the dose must be carefully titrated to obtain the desired blood levels. CNS depression is additive with other CNS depressants such as the opioids.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (General Adverse Reactions of Antiepileptic Drugs [Central Nervous System Depression]) | p. 169 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 7. Which of the following drugs is often used first for treating patients with generalized tonic-clonic

seizures even though it is not Food and Drug Administration (FDA) approved for this use? a. Lamotrigine b. Valproate c. Levetiracetam d. Oxcarbazepine ANS: B

Though not FDA approved, valproate is often used first in treating those patients with generalized tonic-clonic seizures based upon the results presented in the medical literature. Valproate is FDA approved for migraine prophylaxis and bipolar disorder. Lamotrigine is indicated for adjunct therapy in patients 2 years of age with partial seizures, primary generalized tonic-clonic seizures or generalized seizures of the Lennox-Gastaut syndrome. Levetiracetam is indicated for adjunct therapy for adults and children 1 month old with partial seizures, adults and children 6 years of age with primary generalized tonic-clonic seizures, adults and adolescents 12 years old with myoclonic seizures. Oxcarbazepine is indicated for monotherapy and adjunct therapy for partial seizures in adults and children 4 years of age and adjunctive therapy for children 2 years of age.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Valproate) | p. 169 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 8. Valproate is associated with toxicity of which of the following organs? a. Heart b. Kidney c. Liver d. Pancreas ANS: C

Valproate is associated with hepatotoxicity. Dose-related changes in liver enzymes often occur in these patients. Deaths caused by hepatic failure have also been reported. Because valproic acid can produce serious hepatotoxicity, hepatic function tests should be performed. Signs of hepatotoxicity include nausea, vomiting, abdominal pain, loss of appetite, and diarrhea. One of the other choices represents the idiosyncratic toxicity of valproate.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Valproate [Adverse Reactions]) | p. 169 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 9. Lamotrigine (Lamictal) belongs to which of the following classes of antiepileptic drugs? a. Inhibitor of uptake of GABA b. Inactivates sodium channels c. Stabilizes neuronal membranes d. Antagonist to glycine e. Unknown mechanism of action ANS: B

Lamotrigine belongs to the class of sodium channel blocking antiepileptic drugs. Lamotrigine appears to be as effective as carbamazepine and better tolerated in elderly patients newly diagnosed with partial or generalized seizures. Tiagabine (Gabitril) is an inhibitor of GABA uptake. Fosphenytoin (Cerebyx) stabilizes neuronal membranes. Felbamate (Felbatol) is an antagonist to glycine. Levetiracetam (Keppra) and oxcarbazepine (Trileptal) have an unknown mechanism of action.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Lamotrigine) | p. 170 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 10. Which of the following antiepileptic drugs is commonly used as monotherapy for partial onset and

generalized tonic-clonic seizures and may be effective for children with Lennox-Gastaut syndrome? a. Levetiracetam (Keppra) b. Carbamazepine (Tegretol) c. Oxcarbazepine (Trileptal) d. Phenytoin (Dilantin) ANS: A

Levetiracetam (Keppra) is used for partial onset and generalized tonic-clonic seizures and may be effective for children with Lennox-Gastaut syndrome and absence seizures. The benzodiazepine clobazam (Onfi) is used as an adjunctive treatment for seizures associated with Lennox-Gastaut syndrome in patients 2 years of age. Carbamazepine and oxcarbazepine are used to treat partial seizures. Phenytoin IV is used to treat status epilepticus.

DIF: Recall OBJ: 3 11.

REF: Drug Therapy of Patients With Epilepsy (Levetiracetam) | p. 170 TOP: NBDHE, 6.0. Pharmacology

is noted for having cross-sensitivity with carbamazepine in 20% to 30% of patients. a. Lamotrigine b. Valproate c. Levetiracetam

d. Oxcarbazepine ANS: D

Oxcarbazepine is chemically similar to carbamazepine but causes less induction of hepatic enzymes and it does not induce its own metabolism. Cross-sensitivity with carbamazepine occurs in 20% to 30% of patients. Carbamazepine can reduce lamotrigine levels while valproate increases lamotrigine levels more than twofold. No clinically significant drug-drug interactions have been reported with levetiracetam.

DIF: Recall REF: Drug Therapy of Patients With Epilepsy (Oxcarbazepine [Adverse Effects]) | p. 170 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 12. Which antiepileptic agent is commonly prescribed for trigeminal neuralgia? a. Lamotrigine b. Phenytoin c. Gabapentin d. Carbamazepine e. Valproic acid ANS: D

One of the primary uses of carbamazepine is for the treatment of trigeminal neuralgia. It is also indicated in the treatment of bipolar depression. Lamotrigine and gabapentin are not used for pain alleviation. Phenytoin and valproic acid are used but not (or not commonly) for trigeminal neuralgia.

DIF: Recall OBJ: 3

REF: Drug Therapy of Patients With Epilepsy (Carbamazepine) | p. 170 TOP: NBDHE, 6.0. Pharmacology

13. Which of the following agents interferes with platelets? a. Carbamazepine b. Valproic acid c. Ethosuximide d. Both A and B e. Both A and C ANS: D

Carbamazepine and valproic acid can cause thrombocytopenia, a decrease in platelet count. In addition, valproic acid inhibits the second phase of platelet aggregation. Ethosuximide may cause agranulocytosis but does not commonly affect platelets or platelet formation.

DIF: Application REF: Drug Therapy of Patients With Epilepsy (Valproate [Adverse Reactions]) | p. 169 | Drug Therapy of Patients With Epilepsy (Carbamazepine [Adverse Reactions]) | p. 170 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 14. Performing laboratory tests is necessary to monitor patients who are taking carbamazepine. The dental

team should observe the oral cavity for petechiae or signs of infections. a. Both the statement and the reason are correct and related. b. Both the statement and the reason are correct, but they are not related. c. The statement is correct, but the reason is not.

d. The statement is not correct, but the reason is accurate. e. Neither the statement nor the reason is correct.

ANS: A

Carbamazepine can cause blood dyscrasias, which can cause clotting disturbances (petechiae) and compromise immune function (increase infections). The white blood cell count should be monitored.

The dental team should look for petechiae or signs of infection. Fatal blood dyscrasias, including aplastic anemia and agranulocytosis, have been reported related to carbamazepine therapy. Patients should be made aware of these symptoms of blood dyscrasias and warned to stop the drug and report any of the symptoms immediately.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Carbamazepine [Adverse Reactions]) | p. 70 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 15. Alopecia may be observed as an adverse effect of phenytoin. Carbamazepine can cause hirsutism. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: B

The opposite is the case: phenytoin can cause hirsutism, and carbamazepine can cause alopecia. Skin reactions to phenytoin range from rash to exfoliative dermatitis, lupus erythematosus, or StevensJohnson syndrome. Some patients experience hypertrichosis or hirsutism on the trunk and face.

Carbamazepine can cause rashes, urticarial, photosensitivity reactions, and altered skin pigmentation.

Erythema multiforme, erythema nodosum, and aggravation of systemic lupus erythematosus have been reported. Alopecia can also occur.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Carbamazepine [Adverse Reactions]) | p. 172 | Drug Therapy of Patients With Epilepsy (Phenytoin [Adverse Reactions]) | p. 173 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 16. Which agent has a narrow therapeutic index because its metabolism is a saturable process? a. Gabapentin b. Phenobarbital c. Phenytoin d. Valproic acid e. Clonazepam ANS: C

At doses near the therapeutic range, phenytoin can be metabolized by a zero-order kinetic process, meaning that drug metabolism cannot keep up with the level of drug in the body. Drug levels can rise precipitously as a consequence and cause life-threatening toxicity. Phenobarbital, valproic acid, and clonazepam are metabolized in a nonsaturable (first-order kinetic) manner at doses near the therapeutic range. Gabapentin is not metabolized.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Phenytoin [Adverse Reactions]) | p. 173

OBJ: 3

TOP: NBDHE, 6.0. Pharmacology

17. Which antiepileptic medication has been known to produce osteomalacia? a. Carbamazepine b. Phenytoin c. Ethosuximide d. Gabapentin e. Lamotrigine ANS: B

Phenytoin interferes with the metabolism of vitamin D to its active form. In addition, it increases vitamin K metabolism, which is also important for proper bone formation (osteocalcin is a vitamin K– dependent protein). Carbamazepine, ethosuximide, gabapentin, and lamotrigine are not documented to produce osteomalacia.

DIF: Recall REF: Drug Therapy of Patients With Epilepsy (Phenytoin [Adverse Reactions]) | p. 173 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 18. Fetal hydantoin syndrome is associated with maternal ingestion of a. carbamazepine. b. phenobarbital. c. phenytoin. d. gabapentin.

ANS: C

Fetal hydantoin syndrome is the term given to the congenital abnormality associated with maternal ingestion of phenytoin. It includes craniofacial abnormalities, microcephaly, nail or digit hypoplasia, limb defects, growth deficiency, and mental retardation. The other drugs are not associated with fetal hydantoin syndrome.

DIF: Recall REF: Drug Therapy of Patients With Epilepsy (Phenytoin [Adverse Reactions]) | p. 173 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 19. Gingival enlargement may occur in what percentage of chronic users of phenytoin? a. 10% b. 30% c. 50% d. 90% e. None of the above ANS: C

Gingival enlargement occurs in approximately 50% of all chronic users. In approximately 30% of affected patients, gingival enlargement is severe enough to require surgical intervention. The remaining choices do not represent the percentage of gingival enlargement found in chronic users of phenytoin.

DIF: Recall REF: Drug Therapy of Patients With Epilepsy (Phenytoin [Adverse Reactions]) | p. 173

OBJ: 3

TOP: NBDHE, 6.0. Pharmacology

20. Gingival enlargement as a consequence of phenytoin therapy most commonly affects the

facial

gingiva. a. maxillary anterior b. maxillary posterior c. mandibular anterior d. mandibular posterior ANS: A

Gingival enlargement is most commonly seen in the maxillary anterior facial area. Hyperplasia is more commonly located in the anterior rather than the posterior surfaces and the buccal rather than lingual surfaces. The affected areas of the mouth in order of severity are the maxillary anterior facial, mandibular anterior facial, maxillary posterior facial, and mandibular posterior facial areas. Both normal and abnormal tissue may be found in the affected person.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Phenytoin [Adverse Reactions]) | p. 173 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 21. The cause of phenytoin gingival enlargement is a. inhibition of fibroblast activity. b. accumulation of hemosiderin. c. alteration of chemotaxis. d. unknown.

ANS: D

The cause is unknown. Many causes have been investigated, including alteration in the function of the adrenal gland, hypersensitivity or allergic reaction, immunologic reaction, and vitamin C or folate deficiency. None of the other choices are regarded as contributing to phenytoin gingival enlargement.

DIF: Recall REF: Drug Therapy of Patients With Epilepsy (Phenytoin [Adverse Reactions]) | p. 173 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 22. Surgical intervention to reduce phenytoin-induced gingival enlargement should wait until at least 18

months after cessation of therapy because a. the drug remains in circulation for at least 2 years. b. some patients experience additional reduction in the enlargement after the 1-year period. c. excessive sclerosis will result from earlier intervention. d. treating the situation earlier than that will lead to excessive hemorrhage.

ANS: B

Some patients experience additional reduction in the enlargement after the 1-year period. The other choices are not the reason why surgical intervention to reduce phenytoin-induced gingival enlargement is delayed for 18 months following cessation of therapy.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Phenytoin [Adverse Reactions]) | p. 173

OBJ: 3

TOP: NBDHE, 6.0. Pharmacology

23. Ethosuximide is the drug of choice for the treatment of a. generalized tonic-clonic b. generalized absence c. partial simple d. partial complex

seizures.

ANS: B

The drug of choice for the treatment of absence seizures is ethosuximide. Its mechanism of action may involve inhibiting the T-type calcium channels. Ethosuximide is ineffective in partial seizures with complex symptoms or in tonic-clonic seizures.

DIF: Recall OBJ: 4

REF: Drug Therapy of Patients With Epilepsy (Ethosuximide) | p. 174 TOP: NBDHE, 6.0. Pharmacology

24. Clonazepam (Klonopin) is a. a chemical analogue carbamazepine. b. used parenterally to treat status epilepticus. c. used as an adjunct to treat ethosuximide-resistant absence seizures. d. not effective in akinetic seizures. e. an inhibitor of sodium channels.

ANS: C

Clonazepam is effective alone or as an adjunct in the treatment of petit mal seizures. Clonazepam is a benzodiazepine, whereas carbamazepine is a chemical analogue of tricyclic antidepressants and phenothiazines. Clonazepam is not used parenterally. Clonazepam, as with other benzodiazepines, has activity against a wide variety of seizures, including akinetic seizures. The benzodiazepines do not inhibit sodium channels. They bind to the GABA receptor complex and facilitate the entry of chloride into postsynaptic nerve terminals.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Benzodiazepines) | p. 174 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 25. A patient experiencing tonic-clonic seizures should be managed by a. lowering the patient’s head in the dental chair until it is even with the heart. b. tilting the patient’s head to one side to prevent aspiration. c. placing a tongue blade or a pencil between the patient’s teeth. d. having the patient place his or her head between the knees.

ANS: B

The patient’s head should be tilted to one side to prevent aspiration. Management of the patient experiencing tonic-clonic seizures should include moving the patient to the floor if possible, tilting the head to one side, and removing objects from the patient’s mouth before the seizure to prevent fracturing teeth.

DIF: Comprehension REF: Dental Treatment of the Patient With Epilepsy | p. 174 TOP: NBDHE, 6.0. Pharmacology

OBJ: 6

26. Which of the following antiepileptics may be used to manage trigeminal neuralgia? a. Phenytoin b. Carbamazepine c. Ethosuximide d. Valproic acid ANS: B

Carbamazepine is used to treat trigeminal neuralgia and atypical facial pain. Phenytoin has been used to treat neurologic pain. Ethosuximide is used to treat absence seizures. Valproic acid has been used for prophylaxis for migraine headaches.

DIF: Recall OBJ: 6

REF: Nonseizure Uses of Antiepileptics (Neurologic Pain) | p. 174 TOP: NBDHE, 6.0. Pharmacology

27. The drug of choice for treatment of absence seizures is a. brivaracetam. b. eslicarbazepine. c. vigabatrin. d. ethosuximide.

ANS: D

Ethosuximide is the drug of choice in the treatment of typical absence seizures. Brivaracetam is used for partial seizures in patients 16 years of age and older. Eslicarbazepine is used for partial-onset seizures in adults. Lacosamide is used for adults with partial onset seizures. Vigabatrin is used for infantile spasms and as adjunctive therapy for complex partial seizures refractory to other antiepileptic drugs (AEDs) in persons 10 years of age and older.

DIF: Recall OBJ: 1

REF: Epilepsy (Generalized Seizures [Absence Seizures]) | p. 167 TOP: NBDHE, 6.0. Pharmacology

28. Each of the following is an example of a type of generalized seizure except one. Which is the

exception? a. Tonic-clonic b. Myoclonic c. Simple d. Akinetic e. Absence ANS: C

Partial seizures include: simple, complex, secondarily generalized, and temporal lobe. Tonic-clonic, myoclonic, akinetic, and absence are all types of generalized seizures.

DIF: Comprehension REF: Epilepsy (Table 14.1: International Classification of Epileptic Seizures) | p. 168 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 29. Each of following is considered a drug of choice for treatment of generalized tonic-clonic seizures

except one. Which is the exception? a. Levetiracetam

b. Valproate c. Eslicarbazepine d. Lamotrigine ANS: C

Eslicarbazepine (Aptiom) is used as monotherapy and adjunctive therapy for partial-onset seizures.

Valproate, lamotrigine, and levetiracetam are considered the drugs of choice for treatment of generalized tonic-clonic seizures.

DIF: Comprehension REF: Epilepsy (Generalized Seizures [Tonic-Clonic Seizures] [Table 14.2: Antiepileptic Drugs of Choice]) | p.

168 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 30. Which is the most important drug interaction of antiepileptic drugs? a. Precipitation of hypertensive crisis b. Stimulation of hepatic microsomal enzymes c. Allergenicity d. Central nervous system depression ANS: B

Inducing these enzymes results in a reduction in the blood level of the affected drugs. Precipitation of hypertensive crisis or allergenicity is not associated with antiepileptic drugs. Additive central nervous system depression is associated with these drugs so additional CNS depressants should be used cautiously; however, CNS depression is not the most important drug interaction.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Box 14.1: Dental Management of Patients Taking Antiepileptic Agents) | p. 168 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 31. The mechanism of action of vigabatrin is thought to be a. inhibition of voltage-gated sodium channels. b. irreversible inhibition of GABA. c. as an antagonist to glycine. d. stabilization of neuronal membranes.

ANS: B

It is believed to be the result of irreversible GABA inhibition. Eslicarbazepine is thought to inhibit voltage-gated sodium channels. Felbamate is thought to function as an antagonist to glycine.

Fosphenytoin stabilizes neuronal membranes.

DIF: Comprehension REF: Drug Therapy of Patients With Epilepsy (Other Antiepileptic Agents [Table 14.3: Antiepileptic Drugs]) | p. 172 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Which drugs are indicated as first choice drugs for both generalized and partial seizures? (Select all

that apply.) a. Carbamazepine b. Levetiracetam

c. Lamotrigine d. Oxcarbazepine e. Ethosuximide ANS: B, C

Levetiracetam and lamotrigine are drugs of first choice for tonic-clonic, atypical absence, atonic, and myoclonic generalized seizures, and for all types of partial seizures. Carbamazepine and oxcarbazepine are drugs of first choice for partial seizures; however, they are not drugs of first choice for generalized seizures. Ethosuximide is indicated as a first choice for absence generalized seizures.

DIF: Application REF: Epilepsy (Generalized Seizures [Table 14.2: Antiepileptic Drugs of Choice]) | p. 168 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Which of the following are true regarding the dental management of patients taking antiepileptic

agents? (Select all that apply.) a. Antiepileptic agents will exacerbate CNS depression due to other drugs. b. Antiepileptic agents may cause additive gastrointestinal adverse reactions. c. Antiepileptic agents may cause some other drugs to be metabolized more slowly causing cumulative effects. d. Antiepileptic agents will not interact with pain medications or antibiotics used in dentistry.

ANS: A, B

CNS depression is additive with other drugs such as opioids, and additional CNS depressants should be used with caution. Antiepileptic agents will cause additive gastrointestinal adverse reactions, and drugs that will cause gastric irritation should be used cautiously. Antiepileptic drugs cause induction of hepatic microsomal enzymes. This causes certain drugs to be metabolized more quickly. Antiepileptic drugs can interact with dental drugs including propoxyphene and doxycycline.

DIF: Application REF: Drug Therapy of Patients With Epilepsy (General Adverse Reactions of Antiepileptic Drugs [Central Nervous System Depression]) | p. 169 | Drug Therapy of Patients With Epilepsy (General Adverse Reactions of Antiepileptic Drugs [Gastrointestinal Distress]) | p. 169 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Lamotrigine is an effective treatment for myoclonic seizures.

ANS: T

Lamotrigine is indicated for atypical absence, atonic, or myoclonic generalized seizures.

DIF: Recall REF: Epilepsy (Generalized Seizures [Table 14.2: Antiepileptic Drugs of Choice]) | p. 168 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. The better the patient’s oral hygiene is, the less likely that lesions associated with use of phenytoin will

occur.

ANS: T

The better the patient’s oral hygiene, the less likely the lesions are to occur or the less severe they will be if they do occur.

DIF: Recall OBJ: 3

REF: Drug Therapy of Patients With Epilepsy (Phenytoin) | p. 173 TOP: NBDHE, 6.0. Pharmacology

3. Vitamin C is an effective adjunctive therapy for gingival enlargement.

ANS: F

Although vitamin C has been tried in the treatment of gingival enlargement, it has not been shown to be effective in controlled trials.

DIF: Recall OBJ: 3

REF: Drug Therapy of Patients With Epilepsy (Phenytoin) | p. 173 TOP: NBDHE, 6.0. Pharmacology

Chapter 15: Drugs for the Treatment of Central Nervous System Disorders Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which of the following psychiatric disorders involves a loss of the perception of reality? a. Bipolar affective disorder b. Schizophrenia c. Panic disorder d. Obsessive-compulsive disorder ANS: B

Schizophrenia is derived from the word meaning “splitting” and, in context, refers to patient’s splitting from reality. The patient’s ability to function in society is impaired as a result of altered thinking. The other forms of psychiatric disorders do not involve a loss of perception of reality.

DIF: Recall REF: Psychiatric Disorders | p. 176 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. All of the following symptoms are “negative” (passive) symptoms of psychoses except one. Which is

the exception? a. Flat affect b. Vocalization of feelings of superhuman strength c. Abstract thinking difficult d. Social withdrawal e. Thought and speech impaired ANS: B

Vocalization of feelings of superhuman strength is considered a “positive” or active symptom of psychoses because it represents some action. The negative symptoms represent one form of withdrawal or other (i.e., the inability to do or feel something rather than an ability to do or feel something untoward).

DIF: Application

REF: Psychiatric Disorders (Box 15.1: Symptoms of Psychoses) | p. 177

OBJ: 1

TOP: NBDHE, 6.0. Pharmacology

3. The type of depression that exhibits alternating periods of depression and excitation have a(n)

disorder. a. endogenous b. exogenous c. manic-depressive d. reactive ANS: C

Patients who exhibit alternating periods of depression and excitation (mania, elation) have bipolar depression, also known as manic-depressive disorder. Endogenous (involutional) depression seems to be unrelated to external events. Exogenous (reactive) depression appears to be related to specific external events. Major depressive disorder or depression is the result of biologic, psychological, and social factors. Biologic factors are the result of low levels of the neurotransmitters serotonin, norepinephrine, and dopamine levels or a combination of the three in the brain. Psychological and social factors are related to specific external life events.

DIF: Comprehension REF: Psychiatric Disorders | p. 176 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. The amount of any drug prescribed for a depressed patient should not exceed a a. 1 b. 3 c. 7 d. 14

-day supply.

ANS: C

Usually a 1-week supply is the maximum recommended amount. Depressed patients may attempt suicide. The amount of any drug prescribed at one time should not exceed the amount required for a lethal dose, which is usually a 1-week supply.

DIF: Application REF: Antidepressant Agents (Box 15.3: Management of the Dental Patient Taking Antidepressant Agents) | p.

184 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 5. Which of the following agents is classified as an antipsychotic? a. Celexa b. Cephalexin c. Vraylar d. Lexapro e. Bextra ANS: C

Vraylar is the trade name for cariprazine, a newer second-generation antipsychotic. Celexa is the trade name for the antidepressant citalopram, and Lexapro is the trade name for its S-isomer. Cephalexin is a cephalosporin antibiotic, and Bextra is the trade name for valdecoxib, the cyclooxygenase-2 (COX-2) selective nonsteroidal antiinflammatory drug.

DIF: Recall

REF: Antipsychotic Agents (Table 15.1: Antipsychotic Agents) | p. 178

OBJ: 3

TOP: NBDHE, 6.0. Pharmacology

6. In general, lower potency first-generation antipsychotic agents such as chlorpromazine (Thorazine)

will have more of which of the following effects in contrast to the higher potency first-generation antipsychotic agents such as haloperidol (Haldol): (1) sedation, (2) orthostatic hypotension, (3) autonomic effects, (4) extrapyramidal effects? a. 1, 2, 3, 4 b. 1, 2, 3 c. 2, 3, 4 d. 1, 2 e. 3, 4 ANS: B

Chlorpromazine will have more sedation, orthostatic hypotension, and autonomic effects than haloperidol. Lower potency first-generation antipsychotic agents such as chlorpromazine have more sedation, more peripheral side effects, and more autonomic effects. Higher potency first-generation antipsychotics agents such as haloperidol have more extrapyramidal effects and less sedation.

DIF: Application OBJ: 3

REF: Antipsychotic Agents (Table 15.1: Antipsychotic Agents) | p. 178 TOP: NBDHE, 6.0. Pharmacology

7. First-generation antipsychotics would have little effect on which of the following symptoms of

psychosis? a. Delusions b. Unwanted thoughts c. Flat affect d. Agitation e. Disorganized behavior ANS: C

First-generation antipsychotics are active against the positive effects of psychosis but have little effect on the negative effects. Negative symptoms of psychosis include flat affect, unemotional, apathetic, passivity, abstract thinking difficult, lacking spontaneity and goals, impaired thought and speech, lack of pleasure, and social withdrawal. Positive symptoms of psychosis include hallucinations, delusions, unwanted thoughts, disorganized behavior, agitation, and distorted speech and communication.

Second-generation antipsychotics are effective against the negative effects.

DIF: Comprehension REF: Antipsychotic Agents (Pharmacologic Effects [First-Generation Antipsychotics]) | p. 179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 8. First-generation antipsychotics are primarily a. acetylcholine b. norepinephrine c. dopamine d. serotonin (5-hydroxytryptamine) ANS: C

_ antagonists.

First-generation antipsychotics are primarily dopamine antagonists. Second-generation antipsychotic agents have action at more than one receptor, for example, the dopamine, serotonin (5-HT), and norepinephrine (NE) receptors. This results in the improved efficacy of these agents.

DIF: Recall OBJ: 3

REF: Antipsychotic Agents (Mechanism of Action) | p. 178 TOP: NBDHE, 6.0. Pharmacology

9. Tardive dyskinesia is characterized by a. increased compulsive motor activity. b. resting tremor and rigidity. c. akinesia. d. involuntary, repetitive body movements involving the tongue, lips, face, and jaw.

ANS: D

All first-generation antipsychotics produce extrapyramidal effects. Tardive dyskinesia is an irreversible dyskinesia involving the tongue, lips, face, and jaw. These involuntary movements can make home care difficult if not impossible. Performing oral prophylaxis is difficult because of the strength of the oral facial and tongue muscles. Akathisia is an increased compulsive motor activity.

Parkinsonism is characterized by symptoms of resting tremor, rigidity, and akinesia. Akinesia is a loss of voluntary muscle activity.

DIF: Recall REF: Antipsychotic Agents (Pharmacologic Effects [First-Generation Antipsychotics]) | p. 179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 10. Extrapyramidal reactions such as an acute spasm of the mandible caused by first-generation

antipsychotics such as phenothiazines a. can be treated with anticholinergic agents. b. are disorders of muscle control. c. include akathisia. d. All of the above are correct.

ANS: D

Alternatives may include decreasing the dose of the patient’s medication, adding an anticholinergic medication to counteract the spasm, or changing the patient’s antipsychotic medication to one that produces fewer extrapyramidal effects. The anticholinergics used to counteract the extrapyramidal side effects of the antipsychotics include benzotropine (Cogentin) and trihexyphenidyl (Artane). The severity and prevalence of extrapyramidal reactions depends on the balance between acetylcholine and dopamine. Too much dopamine blockade will lead to these side effects. An anticholinergic can partially restore the balance between dopamine and acetylcholine action in specific brain regions associated with muscle control, such as the corpus striatum. Akathisia is an extrapyramidal reaction characterized by increased compulsive motor activity.

DIF: Comprehension REF: Antipsychotic Agents (Pharmacologic Effects [First-Generation Antipsychotics]) | p. 179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 11. Patients taking first-generation antipsychotics can experience severe intermittent temporomandibular

joint (TMJ) pain. This pain is a consequence of a. hyperalgesia produced by a-adrenergic blockade.

b. anticholinergic side effects. c. dislocation of the mandible. d. extrapyramidal side effects.

ANS: D

The extrapyramidal side effects of first-generation antipsychotics can cause severe intermittent pain in the region of the TMJ. This pain is produced by a spasm of the muscles of mastication. -Adrenergic blockade does not produce hyperalgesia, pain is not caused by anticholinergic side effects, and dislocation of the mandible is a possible consequence of a dental practitioner attempting to force open the mouth of a patient who is experiencing a spasm of the muscles of mastication.

DIF: Comprehension REF: Antipsychotic Agents (Pharmacologic Effects [First-Generation Antipsychotics]) | p. 179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 12. Phenothiazines cause orthostatic hypotension by blocking which receptor? a. -Adrenergic b. -Adrenergic c. Dopamine d. Acetylcholine ANS: A

Phenothiazines, first-generation antipsychotics, cause orthostatic hypotension by blocking adrenergic receptors. These agents depress the central sympathetic outflow and block the peripheral adrenergic receptors; they can produce orthostatic hypotension that is additive with other CNS depressants. When a patient rises rapidly from the supine position, a compensatory tachycardia can accompany the orthostatic hypotension.

DIF: Recall REF: Antipsychotic Agents (Pharmacologic Effects [First-Generation Antipsychotics]) | p. 179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 13. Which of the following second-generation antipsychotics is associated with agranulocytosis? a. Aripiprazole b. Clozapine c. Quetiapine d. Risperidone e. Ziprasidone ANS: B

Clozapine causes agranulocytosis or granulocytopenia in about 1% of patients taking it. With the release of newer second-generation antipsychotic agents, use of this agent has decreased. Clozapine should be tried only after several trials of other agents have failed because it produces a potentially life-threatening agranulocytosis. Frequent white blood cell counts with differential are required during therapy.

DIF: Recall REF: Antipsychotic Agents (Pharmacologic Effects [Second-Generation Antipsychotics]) | p. 180 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

14. Epinephrine should not be used to treat vasomotor collapse in patients taking first-generation

antipsychotics because the first-generation antipsychotics are a. -adrenergic stimulators. b. -adrenergic blockers. c. -adrenergic stimulators. d. -adrenergic blockers.

ANS: B

The first-generation antipsychotics are -adrenergic blockers. Epinephrine should not be used to treat vasomotor collapse in patients taking first-generation antipsychotics because it could cause a further decrease in blood pressure. This occurs as a result of the predominant -agonist activity of epinephrine in the presence of the first-generation antipsychotics (-blockers).

DIF: Recall OBJ: 3

REF: Antipsychotic Agents (Drug Interactions [Epinephrine]) | p. 180 TOP: NBDHE, 6.0. Pharmacology

15. First-generation antipsychotic therapy must often be combined with

drugs such as benztropine

to control excessive extrapyramidal stimulation. a. adrenergic b. antiadrenergic c. cholinergic d. anticholinergic ANS: D

To control excessive extrapyramidal stimulation, first-generation antipsychotic therapy is often combined with anticholinergic drugs such as benztropine (Cogentin) and trihexyphenidyl (Artane).

This combination is likely to exacerbate antimuscarinic peripheral effects such as xerostomia, urinary retention, constipation, blurred vision, and inhibition of sweating.

DIF: Comprehension REF: Antipsychotic Agents (Drug Interactions [Anticholinergic Agents]) | p. 180 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 16. Which of the following choices is recommended to counteract the anticholinergic effects of first-

generation antipsychotics? a. Caffeine-containing beverages b. Alcohol-containing mouth rinses c. Sugarless products or artificial saliva d. Sugar-containing candy ANS: C

First-generation antipsychotics are additive with other agents with atropine-like effects. Use of sugarless products or artificial saliva should be encouraged. Patients should be encouraged to stay away from caffeine-containing beverages because they can exacerbate dry mouth. They should also avoid alcohol-containing mouth rinses because alcohol can also exacerbate dry mouth. Patients may use sugar-containing candy to counteract xerostomia. Use of sugarless products is recommended.

DIF: Comprehension REF: Antipsychotic Agents (Dental Implications [Anticholinergic Effects]) | p. 180

OBJ: 3

TOP: NBDHE, 6.0. Pharmacology

17. Which of the following are adverse reactions associated with selective serotonin reuptake inhibitors

(SSRIs)? a. Central nervous system (CNS) depression b. Nausea and diarrhea in approximately 15% to 30% of patients c. Xerostomia in 10% to 15% of the population d. Both A and B e. Both B and C ANS: E

SSRIs are recommended as first-line therapy for the treatment of major depression. They are associated with nausea and diarrhea in approximately 15% to 30% of patients. Oral side effects include xerostomia in 10% to 15% of the population, taste changes, aphthous stomatitis, glossitis, and (rarely) increased salivation, salivary gland enlargement, and tongue discoloration or edema. SSRIs tend to produce CNS stimulation rather than CNS depression.

DIF: Comprehension REF: Antidepressant Agents (Selective Serotonin Reuptake Inhibitors [Adverse Reactions]) | p. 181 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 18. Which antidepressant is least likely to cause xerostomia? a. Bupropion b. Sertraline c. Chlorpromazine d. Amitriptyline e. Trazodone ANS: B

Sertraline, as with other SSRIs, produces a lower incidence of xerostomia than other classes of antidepressants, probably because their anticholinergic activity is significantly weaker. Bupropion, trazodone, and especially amitriptyline have a greater anticholinergic action and incidence of xerostomia. Chlorpromazine is not an antidepressant.

DIF: Application REF: Antidepressant Agents (Table 15.3: Commonly Used Antidepressants) | p. 182 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 19. Abrupt withdrawal of serotonin-norepinephrine reuptake inhibitors (SNRIs) can lead to symptoms of a. urinary retention. b. anxiety. c. tachycardia. d. sweating.

ANS: B

Abrupt discontinuation can lead to withdrawal characterized by symptoms of anxiety, which may be attributed to their short half-lives. Adverse effects of SNRIs can include sweating, tachycardia, and urinary retention.

DIF: Recall

REF: Antidepressant Agents (Serotonin-Norepinephrine Reuptake Inhibitors) | p. 183 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 20. Which of the following are anticholinergic effects that may be associated with tricyclic

antidepressants? a. Xerostomia b. Bradycardia c. Urination d. Both A and B e. Both B and C ANS: A

Tricyclic antidepressants possess distinct anticholinergic effects resulting in xerostomia, blurred vision, tachycardia, constipation, and urinary retention. Some tolerance can develop with continued use. The extension of cholinergic effects are salivation, lacrimation, urination, and defecation.

Anticholinergic effects would be the opposite.

DIF: Comprehension REF: Antidepressant Agents (Tricyclic Antidepressants [Adverse Reactions]) | p. 183 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 21. Which of the following side effects is the most serious peripheral side effect associated with the use of

tricyclic antidepressants? a. Orthostatic hypotension b. Cardiac toxicity c. Urination d. Bradycardia ANS: B

The most serious peripheral side effect associated with the tricyclic antidepressants is cardiac toxicity.

Myocardial infarction and congestive heart failure have occurred during the course of treatment.

Orthostatic hypotension is associated with antipsychotics. Tricyclic antidepressants are associated with anticholinergic effects such as xerostomia, tachycardia, constipation, and urinary retention.

Arrhythmias and episodes of tachycardia can be caused by the antimuscarinic effects of the tricyclic antidepressants.

DIF: Comprehension REF: Antidepressant Agents (Tricyclic Antidepressants [Adverse Reactions]) | p. 184 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 22. Of the tricyclic antidepressants listed, which one is most sedating? a. Imipramine b. Nortriptyline c. Protriptyline d. Desipramine e. Amitriptyline ANS: E

Amitriptyline is used when sedation is desired. Of the tricyclic antidepressants listed, amitriptyline is generally the most sedating, with desipramine being the least sedating. When less sedation is needed, nortriptyline or protriptyline can be tried.

DIF: Comprehension REF: Antidepressant Agents (Table 15.3: Commonly Used Antidepressants) | p. 182 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 23. Which of the following types of dental medicaments must be administered with caution to patients

taking tricyclic antidepressants? a. Fluoride b. Antibiotics c. Anesthetics d. Analgesics ANS: C

The cardiac dose (0.04 mg) of local anesthetics can be safely administered to patients who do not have preexisting arrhythmias. Vasoconstricting drugs in local anesthetic solution must be administered with caution to patients taking tricyclic antidepressants. They may potentiate vasopressor response to epinephrine.

DIF: Application REF: Antidepressant Agents (Tricyclic Antidepressants [Drug Interactions]) | p. 184 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 24. Bupropion is reserved for patients who are not responsive to other agents because of a potential for a. cardiac arrhythmias. b. seizures. c. retinopathy. d. glaucoma.

ANS: B

Because of its seizure potential, bupropion is reserved for patients who are not responsive to other agents. Approximately 0.4% of patients treated with bupropion have experienced seizures. This incidence may be four times greater than with tricyclic antidepressants and as much as 10 times greater with tricyclic antidepressants at higher doses.

DIF: Recall OBJ: 5

REF: Antidepressant Agents (Other Antidepressants [Bupropion]) | p. 184 TOP: NBDHE, 6.0. Pharmacology

25. Which antidepressant drug carries a “black box” warning regarding its potential to cause life-

threatening liver failure? a. Imipramine b. Bupropion c. Nefazodone d. Mirtazapine e. Venlafaxine ANS: C

Nefazodone has the potential to cause fatal hepatic dysfunction. The remaining choices do not have a “black box” warning regarding the potential for causing liver failure. All antidepressants carry a black box warning about suicidal ideation and behavior. Imipramine is a tricyclic-tertiary amine. The most serious side effect with tricyclic antidepressants (TCAs) is cardiac toxicity. Bupropion carries a risk for seizures. Mirtazapine causes somnolence, weight gain, constipation, and dry mouth. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor. Abrupt withdrawal is characterized by symptoms of anxiety.

DIF: Comprehension REF: Antidepressant Agents (Other Antidepressants [Nefazodone, Mirtazapine, and Vilazodone]) | p. 184 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 26. Interaction of monoamine oxidase inhibitors (MAOIs) with many drugs such as amphetamines, and

with foods such as wines, cheese, and fish, can precipitate a. hair loss. b. hypertensive crisis. c. gout. d. dysgeusia.

ANS: B

Patients taking MAOIs have detailed food prohibitions because of this chance of food-drug interactions. MAOIs interaction with many drugs and foods can precipitate a hypertensive crisis and even death. MAOIs are used as drugs of last choice. Patients taking MAOIs should not be given any drug unless the prescriber has first consulted a reference source on drug interactions.

DIF: Recall OBJ: 4

REF: Antidepressant Agents (Monoamine Oxidase Inhibitors) | p. 184 TOP: NBDHE, 6.0. Pharmacology

27. Dental local anesthetic with vasoconstricting agents must be limited to the cardiac dose for patients

taking a. first-generation antipsychotic agents. b. second-generation antipsychotic agents. c. tricyclic antidepressants (TCAs). d. drugs for treatment of bipolar disorder.

ANS: C

TCAs may potentiate vasopressor response to epinephrine. The sympathomimetic amines present in a dental local anesthetic solution can be safely administered to patients without preexisting arrhythmias.

Caution should be used if epinephrine is necessary in a patient receiving the SSRIs citalopram (Celexa) or escitalopram (Lexapro). Vasoconstricting drugs in the local anesthetic solution must be administered with caution to patients taking TCAs. Epinephrine should be avoided in the management of an acute hypotensive crisis in a patient taking an antipsychotic. Epinephrine may be used with antipsychotics.

DIF: Comprehension REF: Antipsychotic Agents (Dental Implications [Epinephrine]) | p. 181 | Antidepressant Agents (Dental Implications [Sympathomimetic Amines]) | p. 184 OBJ: 3|5 TOP: NBDHE, 6.0. Pharmacology 28. Which of the following medications is used to treat bipolar depression?

a. b. c. d.

Haloperidol Lithium Clozapine Paroxetine

ANS: B

Lithium is used in the treatment of bipolar depression, which is characterized by cyclic recurrence of mania alternating with depression. Haloperidol is a high-potency first-generation antipsychotic.

Clozapine is a second-generation antidepressant. Paroxetine is an SSRI. DIF: Recall OBJ: 6

REF: Drugs for Treatment of Bipolar Disorder | p. 185 TOP: NBDHE, 6.0. Pharmacology

29. Patients undergoing lithium therapy should be observed for signs of overdose toxicity, including a. hyperpyrexia. b. constipation. c. muscle rigidity and fasciculations. d. loquacious speech.

ANS: C

Overdose toxicity may be exhibited by CNS symptoms, including muscle rigidity, hyperactive deep reflexes, excessive tremor, and muscle fasciculations. Side effects of treatment with lithium include polyuria, fine hand tremor, thirst, and in more severe cases, slurred speech, ataxia, nausea, vomiting, and diarrhea.

DIF: Comprehension REF: Drugs for Treatment of Bipolar Disorder (Lithium) | p. 185 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 30. Which of the following categories of medications has recently been approved for the treatment of

bipolar disorder? a. High-potency first-generation antipsychotics b. Second-generation antipsychotics c. SSRIs d. MAOIs ANS: B

Olanzapine and aripiprazole are approved for relapse prevention of bipolar disorder. All of the secondgeneration antipsychotics have been approved for the treatment of bipolar disorder, as well as for the acute treatment of bipolar disorder.

DIF: Recall REF: Drugs for Treatment of Bipolar Disorder (Second-Generation Antipsychotics) | p. 185 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 31. Which of the following antipsychotic agents have been approved for adjunctive treatment of major

depressive disorder? a. Low potency first-generation antipsychotics b. Medium potency first-generation antipsychotics c. High potency first-generation antipsychotics

d. Second-generation antipsychotics ANS: D

Several second-generation antipsychotics have been FDA-approved for adjunctive treatment of major depressive disorder. A fixed-dose combination of olanzapine and fluoxetine (Symbyax) is FDAapproved for treatment-resistant depression. It is second-generation antipsychotics and not firstgeneration antipsychotics that have been approved for treatment of major depressive disorder.

DIF: Comprehension REF: Antidepressant Agents (Second Generation Antipsychotics) | p. 185 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 32. Which choice represents the current most commonly prescribed antidepressant agent? a. Monoamine oxidase inhibitor (MAOI) b. Tricyclic antidepressant (TCA) c. Selective serotonin uptake inhibitor (SSRI) d. Second-generation antipsychotic ANS: C

SSRIs are recommended as first-line therapy for the treatment of major depression. They are generally well tolerated, safe, and effective. MAOIs are used as drugs of last choice because of the potential for life-threatening situations. TCAs are no longer first-line therapy and are reserved for patients with moderate to severe treatment-resistant depression. Several second-generation antipsychotics have been FDA-approved for adjunctive treatment of major depressive disorder.

DIF: Comprehension REF: Antidepressant Agents (Selective Serotonin Reuptake Inhibitors [Adverse Reactions]) | p. 181 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 33. Second-generation antipsychotics are primarily antagonists at all of the following receptor types except

one. Which is the exception? a. Acetylcholine b. Norepinephrine (NE) c. Dopamine d. Serotonin (5-HT) ANS: A

Antipsychotic agents are not antagonists for acetylcholine. First-generation antipsychotic agents were primarily dopamine antagonists; however, second-generation agents have action at more than one receptor, including dopamine, serotonin (5-HT), and norepinephrine receptors. This improves their efficacy.

DIF: Comprehension REF: Antipsychotic Agents (Mechanism of Action) | pp. 178-179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 34. Which works most quickly for a suicidal patient? a. Bupropion b. Monoamine oxidase inhibitor c. Selective serotonin reuptake inhibitor

d. Serotonin-norepinephrine reuptake inhibitor e. Electroconvulsive therapy (ECT) ANS: E

ECT produces the fastest results of any treatment for depression. It is reserved for patients whose disease is refractive to antidepressant therapy. ECT is still used in the treatment of depression. ECT therapy has become much safer with the use of neuromuscular blocking agents.

DIF: Recall REF: Psychiatric Disorders | p. 177 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

35. Which was the first selective serotonin reuptake inhibitor (SSRI)? a. Sertraline (Zoloft) b. Fluoxetine (Prozac) c. Paroxetine (Paxil) d. Citalopram (Celexa) e. Escitalopram (Lexapro) ANS: B

Fluoxetine (Prozac) was the first SSRI. Selective serotonin reuptake inhibitors are recommended as first-line therapy for the treatment of major depression. Their antidepressant action is equivalent to that of tricyclic antidepressants (TCAs), and their advantage over TCAs is due to their adverse reaction profile. Fluoxetine was the first. There is no convincing data showing that one is better than another.

DIF: Recall OBJ: 4

REF: Antidepressant Agents (Selective Serotonin Reuptake Inhibitors) | p. 181 TOP: NBDHE, 6.0. Pharmacology

36. Which antidepressant is associated with priapism? a. Bupropion b. Tricyclic antidepressants c. Trazodone d. Nefazodone e. Mirtazapine ANS: C

Trazodone is highly sedative and has been associated with priapism requiring surgical intervention and leaving some patients permanently impotent. Bupropion is associated with seizures. Tricyclic antidepressants are associated with anticholinergic effects and cardiac toxicity. Nefazodone carries a black box warning regarding the potential to cause life-threatening liver failure. Mirtazapine causes somnolence, weight gain, constipation, and dry mouth.

DIF: Recall OBJ: 5

REF: Antidepressant Agents (Other Antidepressants [Trazodone]) | p. 184 TOP: NBDHE, 6.0. Pharmacology

37. Deutetrabenazine (Austedo) is used to treat: a. Manic-depressive disorder b. Schizophrenia c. Obsessive-compulsive disorder d. Tardive dyskinesia

ANS: D

Antipsychotic drugs can cause tardive dyskinesia. deutetrabenazine (Austedo) and valbenazine (Ingrezza) selectively inhibit vesicular monoamine transporter 2 (VMAT2) in presynaptic neurons.

DIF: Recall REF: Antipsychotic Agents (Pharmacologic Effects [Treatment of Tardive Dyskinesia]) | p. 180 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Which of the following are true of second-generation antipsychotics in contrast to first-generation

antipsychotics? (Select all that apply.) a. Second-generation antipsychotics are used more frequently than first-generation antipsychotics. b. Second-generation antipsychotics are better tolerated than first-generation antipsychotics. c. Second-generation antipsychotics are more effective against the negative effects of psychosis than first-generation antipsychotics. d. Second-generation antipsychotics are primarily dopamine antagonists, whereas first-generation antipsychotics were dopamine agonists.

ANS: A, B, C

The second-generation antipsychotics are now used more commonly than the first-generation antipsychotics even though clinical trials have not demonstrated a clear advantage in efficacy, except for clozapine and possible olanzapine. However, second-generation antipsychotics are better tolerated.

Like the first-generation antipsychotics, the second-generation antipsychotics are effective against the positive effects associated with psychoses. Unlike the first-generation antipsychotics, however, the second-generation antipsychotic agents are effective against the negative effects. The first-generation antipsychotic agents were primarily dopamine antagonists. The second-generation agents have action at more than one receptor, for example, the dopamine, serotonin (5-HT), and norepinephrine (NE) receptors.

DIF: Application REF: Antipsychotic Agents | p. 178 | Antipsychotic Agents (Mechanism of Action) | pp. 178-179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 2. Serotonin-norepinephrine reuptake inhibitors (SNRIs): (Select all that apply.) a. are considered first-line therapy for the treatment of depression. b. are considered superior to selective serotonin reuptake inhibitors (SSRIs). c. can induce withdrawal symptoms if abruptly discontinued. d. are antipsychotic agents.

ANS: A, C

SNRIs and SSRIs are both considered first-line therapy for the treatment of depression. These drugs should be slowly tapered off to reduce the risk of withdrawal. It is not clear if SNRIs offer any advantage over SSRIs. SNRIs are antidepressants, not antipsychotics.

DIF: Application REF: Antidepressant Agents (Serotonin-Norepinephrine Reuptake Inhibitors) | p. 183

OBJ: 4

TOP: NBDHE, 6.0. Pharmacology

TRUE/FALSE 1. Second-generation antipsychotics have fewer side effects than first-generation antipsychotics.

ANS: T

As with first-generation antipsychotics, the second-generation antipsychotics are effective against the positive effects associated with psychoses. Unlike first-generation antipsychotics, however, the second-generation antipsychotics are effective against the negative effects.

DIF: Recall OBJ: 3

REF: Antipsychotic Agents (Mechanism of Action) | p. 179 TOP: NBDHE, 6.0. Pharmacology

2. Force should be exerted to open the patient’s mouth if muscle spasm is present as a result of tardive

dyskinesia.

ANS: F

Forces should not be exerted to open the patient’s mouth for dental treatment because dislocations of the mandible can occur.

DIF: Recall REF: Antipsychotic Agents (Pharmacologic Effects [First-Generation Antipsychotics]) | p. 179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 3. Intractable hiccups have been successfully treated with first-generation antipsychotics.

ANS: T

Hiccups and certain drug withdrawals have been treated with first-generation antipsychotics.

DIF: Recall OBJ: 3

REF: Antipsychotic Agents (Uses [Other Uses]) | p. 181 TOP: NBDHE, 6.0. Pharmacology

4. The chemoreceptor trigger zone (CTZ) is a site of action for prochlorperazine.

ANS: T

Prochlorperazine is a phenothiazine. It is an antiemetic compound by virtue of the ability to depress the CTZ. DIF: Comprehension REF: Antipsychotic Agents (Pharmacologic Effects [First-Generation Antipsychotics]) | p. 179 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 5. SSRIs tend to produce CNS stimulation rather than CNS depression.

ANS: T

SSRIs do not have the sedative actions found in many tricyclic antidepressants. As a class, they tend to be less sedating, although sedation is sometimes seen with some members of this class (e.g., sertraline).

DIF: Recall REF: Antidepressant Agents (Selective Serotonin Reuptake Inhibitors [Adverse Reactions]) | p. 181 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 6. All antidepressants will carry a black box warning about the potential for patient suicide.

ANS: T

There is an increased risk of suicidality in children, adolescents, and young adults, which are included in the package inserts. All depressed children, adolescents, and adults should be monitored for suicidal ideation and behavior regardless of antidepressant or nontherapy.

DIF: Recall OBJ: 4

REF: Antidepressant Agents (Suicide and Antidepressants) | p. 184 TOP: NBDHE, 6.0. Pharmacology

Chapter 16: Adrenocorticosteroids Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Adrenocorticosteroids are released from the a. hypothalamus. b. adrenal cortex. c. pituitary gland. d. adrenal medulla. e. kidney.

ANS: B

Adrenocorticosteroids are released from the adrenal cortex. The hypothalamus releases corticotrophinreleasing factor. The pituitary gland releases adrenocorticotropic hormone (ACTH), and the adrenal cortex releases adrenocorticosteroids. The adrenal medulla, which releases adrenaline, and the kidney, under which the adrenal gland is found, are not part of the endocrine pathway for the release of adrenocorticosteroids.

DIF: Recall REF: Mechanism of Release | p. 187 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. ACTH is secreted from the in response to . a. hypothalamus; stress b. adrenal cortex; corticotropin-releasing hormone (CRH) c. adrenal cortex; stress d. hypothalamus; hydrocortisone e. pituitary gland; CRH ANS: E

Under the influence of CRH, the pituitary gland secretes ACTH, which stimulates the adrenal cortex to release hydrocortisone. Stress causes the hypothalamus to release CRH, which acts on the pituitary gland.

DIF: Comprehension REF: Mechanism of Release | p. 187 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology

3. Negative feedback involves the action of adrenocorticosteroids on the a. adrenal cortex. b. pituitary gland. c. hypothalamus. d. Both A and C are correct. e. Both B and C are correct.

ANS: E

Adrenocorticosteroids act on both the pituitary gland and the hypothalamus to inhibit the release of CRH and ACTH, respectively. This mechanism is called negative feedback. Negative feedback does not involve the action of adrenocorticosteroids on the adrenal cortex.

DIF: Comprehension REF: Mechanism of Release | p. 187 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. Without stress, the normal adult secretes approximately a. 20 mg b. 40 mg c. 5 mg d. 40 g e. 10 mg

of hydrocortisone daily.

ANS: A

The normal adult secretes approximately 20 mg of hydrocortisone daily. A tenfold increase can occur with stress. The other choices do not represent the amount of hydrocortisone that a normal adult secretes every day.

DIF: Recall REF: Classification | p. 187 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

5. When does the maximal secretion of hydrocortisone (cortisol) occur in the body? a. Between 12 PM and 2 PM b. Between 9 AM and 12 AM c. Between 4 AM and 8 AM d. Between 7 AM and 10 AM ANS: C

The maximal secretion of cortisol occurs between 4 AM and 8 AM in people with a normal schedule.

The other choices are not the time period where people with a normal schedule secrete the most cortisol.

DIF: Recall REF: Classification | p. 187 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

6. Which of the following choices is a disease or condition produced by an excess of

adrenocorticosteroids? a. Addison disease b. Cushing syndrome c. Graves’ disease

d. Parkinson disease ANS: B

Cushing syndrome is produced by an excess of adrenocorticosteroids. Glucocorticoid therapy can give patients an appearance of Cushing syndrome. Moon face (round), buffalo hump (fat deposited on the back of the neck), truncal obesity, weight gain, and muscle wasting give patients the Cushing syndrome appearance. The remaining choices are not diseases produced by an excess of adrenocorticosteroids.

DIF: Recall REF: Definitions | p. 187 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

7. Of the following agents listed, which is the most potent in glucocorticoid activity? a. Hydrocortisone (Cortaid, Anusol, Hytone, Dermacort, Penecort, Cetacort) b. Fluocinolone acetonide (Synalar) c. Betamethasone valerate (Valisone) d. Triamcinolone acetonide (Aristocort) e. Clobetasol propionate (Temovate) ANS: E

Clobetasol propionate (Temovate) has super high potency. Betamethasone has medium potency.

Hydrocortisone, triamcinolone acetonide, and fluocinolone acetonide all have low potency.

DIF: Comprehension REF: Routes of Administration (Table 16.1: Relative Potency of Selected Topical Corticosteroid Products) | p.

188 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 8. A 5-mg oral dose of hydrocortisone (Cortisol) would be equivalent to what dose of triamcinolone? a. 1 mg b. 2 mg c. 5 mg d. 10 mg e. 20 mg ANS: A

A 4-mg dose of triamcinolone, which is an intermediate acting oral corticosteroid, is equivalent to 20 mg of hydrocortisone, which is a short-acting oral corticosteroid. Thus, 1 mg of triamcinolone is equivalent to 5 mg of hydrocortisone. The remaining choices do not represent the equivalent oral dose of hydrocortisone and triamcinolone.

DIF: Application REF: Corticosteroid Products (Table 16.2: Selected Oral Corticosteroids) | p. 191 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 9. Glucocorticoids cause an increase in the circulating levels of which of the following white blood cells? a. T lymphocytes b. B lymphocytes c. Neutrophils d. Basophils e. Monocytes

ANS: C

The use of steroids results in an increase in the concentration of neutrophils. Steroids induce the synthesis of a protein that inhibits phospholipase A, decreasing the production of both prostaglandins and leukotrienes from arachidonic acid. Glucocorticoids decrease the circulating levels of T lymphocytes, B lymphocytes, basophils, eosinophils, and monocytes.

DIF: Comprehension REF: Mechanism of Action | p. 188 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 10. All of the following are signs of Cushing syndrome except for which one? a. Moon face b. Hypoglycemia c. Muscle wasting d. Fat deposit on back of neck ANS: B

Cushing syndrome is caused by an overabundance of corticosteroids. Glucocorticoids increase gluconeogenesis and decrease glucose usage, allowing a higher glucose concentration in the blood.

Hyperglycemia may be aggravated or initiated especially in prediabetic patients. Cushing syndrome causes moon (round) face, muscle wasting, and buffalo hump (fat deposit on back of neck).

DIF: Comprehension REF: Adverse Reactions (Metabolic Changes) | p. 188 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 11. Patients taking corticosteroids may have mucosal surfaces that are more a. calloused b. friable c. keratinized d. stippled

than other patients.

ANS: B

The catabolic effects of steroids that result from impaired synthesis of collagen can impair wound healing. The mucosal surfaces of patients taking corticosteroids heal more slowly, are more likely to have infection, and are more friable. Oral candidiasis may result with the use of oral steroid inhalers for asthma.

DIF: Recall OBJ: 3

REF: Adverse Reactions (Dental Effects) | p. 190 TOP: NBDHE, 6.0. Pharmacology

12. The most extensive use of the corticosteroids in both medicine and dentistry is in a. replacement therapy for corticosteroid deficiency. b. cancer chemotherapy. c. to prevent organ transplant rejection. d. osteoporosis. e. inflammatory and allergic conditions.

ANS: E

The most extensive use of the corticosteroids in both medicine and dentistry is in the treatment of a wide variety of inflammatory and allergic conditions. Replacement therapy for corticosteroid deficiency, cancer chemotherapy, and prevention of organ transplant rejection are all valid uses of corticosteroids, but they account for fewer prescriptions than inflammation and allergy. Corticosteroids can exacerbate osteoporosis and are not used in its treatment.

DIF: Comprehension REF: Pharmacologic Effects | p. 188 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. For which type of oral lesion would glucocorticoids be contraindicated? a. Desquamative gingivitis b. Herpetic gingivostomatitis c. Pemphigus d. Erythema multiforme e. Benign mucous membrane pemphigoid ANS: B

Herpes is a viral infection. A lesion of infectious etiology, such as herpes, must be ruled out because glucocorticoids can exacerbate infections. Desquamative gingivitis, pemphigus, erythema multiforme, and benign mucous membrane pemphigoid are all noninfectious lesions.

DIF: Comprehension REF: Uses (Dental Uses [Oral Lesions]) | p. 191 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 14. The mineralocorticoid effects of corticosteroids include all of the following except which one? a. Increased sodium retention b. Decreased potassium retention c. Decreased bone density d. Edema e. Hypertension ANS: C

Changes in bone density are glucocorticoid effects of corticosteroids. These agents can promote osteoporosis. These patients are more likely to suffer fractures either with or without trauma.

Mineralocorticoids increase sodium retention, decrease potassium retention, and increase blood volume, leading to edema and contributing to hypertension and congestive heart failure.

DIF: Comprehension REF: Pharmacologic Effects (Box 16.1: Glucocorticoid and Mineralocorticoid Effects) | p. 190 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 15. The inflammatory activity of the adrenocorticosteroids may cause them to mask the symptoms of an

infection. Adrenocorticosteroids decrease a patient’s ability to fight infection by suppression of migration of plasma cells. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second statement is false. d. The first statement is false; the second statement is true.

ANS: C

Adrenocorticosteroids may mask symptoms of an infection, but they decrease a patient’s ability to fight infection by suppression of the migration of polymorphonuclear leukocytes rather than plasma cells. Plasma cells arrive relatively late in the sequence of an inflammatory response.

Polymorphonuclear leukocytes are the first to arrive at the site of injury.

DIF: Comprehension REF: Dental Implications (Adverse Reactions [Infection]) | p. 193 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 16. Which of the following statements is true concerning adrenal crisis? a. Once adrenal suppression occurs, the adrenal gland will never respond normally

again. b. The adrenal crisis occurs because of a relative lack of corticosteroids during stress. c. Administering adrenal steroids may be necessary after a stressful dental procedure

to prevent adrenal crisis. d. Problems generally occur with either low or very high doses, not in the midrange.

ANS: B

Adrenal crisis occurs because of a relative lack of corticosteroids during stress, such as a dental appointment for a patient with dental phobia. Suppression of the hypothalamic-pituitary-adrenal axis occurs with prolonged administration of steroids. Once adrenal suppression occurs, it can take weeks or months for the adrenal gland to respond normally. Adrenal steroids may need to be administered before a stressful dental procedure to prevent crisis. Generally, low and very high doses do not present problems; problems occur with midrange doses.

DIF: Comprehension REF: Dental Implications (Adverse Reactions [Adrenal Crisis]) | p. 193 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 17. Which of the following types of patients is least likely to require steroid supplementation for most

routine dental procedures? a. A patient with primary adrenal insufficiency b. A patient with secondary adrenal insufficiency c. A patient with Addison disease d. A patient with rheumatoid arthritis ANS: B

More often than not, patients with secondary adrenal insufficiency do not normally require steroid supplementation for most routine dental procedures, including nonsurgical periodontal therapy.

Patients with primary adrenal insufficiency are more likely to be at higher risk than those with secondary adrenal insufficiency. Several researchers have found that adrenal crisis is a rare event in dentistry, especially for patients with secondary adrenal insufficiency. At risk diseases include Addison disease, rheumatoid arthritis, Cushing syndrome, asthma, lupus erythematosus, psoriasis, and scleroderma.

DIF: Comprehension REF: Dental Implications (Steroid Supplementation) | p. 193 TOP: NBDHE, 6.0. Pharmacology

OBJ: 5

18. Patients who are on which of the following corticosteroid regimens should be prescribed supplemental

corticosteroids before a stressful dental procedure? a. Currently taking less than 20 mg of hydrocortisone every day b. Currently taking more than 40 mg of hydrocortisone every day c. Currently taking between 20 and 40 mg of hydrocortisone every day d. All of the above e. None of the above ANS: C

With some intermediate doses of steroids (estimated to be between 20 and 40 mg/day hydrocortisone or 5 and 10 mg prednisone/day), additional steroids may be indicated if the procedure will produce severe stress. The patient’s physician should always be consulted if there is any doubt as to whether or not to supplement. Steroid supplementation is sometimes needed for patients taking steroids if they will be subjected to a stressful procedure because of the way exogenous corticosteroids affect the body’s ability to produce their own steroids. With both low doses (<20 mg hydrocortisone or 5 mg prednisone) and very high doses (immunosuppressive; >40 to 60 mg hydrocortisone/day or 10 to 15 mg prednisone/day), no additional steroid supplementation is needed.

DIF: Recall OBJ: 5

REF: Dental Implications (Steroid Supplementation) | p. 193 TOP: NBDHE, 6.0. Pharmacology

19. Which is released by the adrenal cortex in response to the release of adrenocorticotropic hormone

(ACTH)? a. Corticotropin-releasing hormone (CRH) b. Hydrocortisone c. Adrenocorticotropic hormone ACTH d. Norepinephrine e. Acetylcholine ANS: B

The adrenal cortex releases hydrocortisone. Hydrocortisone acts on the pituitary and hypothalamus to inhibit the release of corticotropin-releasing hormone and adrenocorticotropic hormone. The hypothalamus releases CRH. The pituitary gland releases ACTH under the influence of CRH. Stress and anxiety cause the higher centers to release norepinephrine and acetylcholine.

DIF: Comprehension REF: Mechanism of Release | p. 187 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 20. Each of the following will be reduced by glucocorticoid excess except one. Which is the exception? a. Secretion of growth hormone b. Bone formation c. Linear growth d. Insulin resistance e. Visceral obesity ANS: D

Carbohydrate/lipid metabolism, including hepatic glycogen deposition, peripheral insulin resistance, gluconeogenesis, and free fatty acid production, will increase. Growth hormone secretion, bone formation and bone mass, and linear growth all will decrease. Glucocorticoid excess promotes visceral obesity.

DIF: Application REF: Pharmacologic Effects | p. 188 TOP: NBDHE, 6.0. Pharmacology 21. A deficiency of adrenocorticosteroids is a. Addison disease; Cushing disease b. Addison disease; Cushing syndrome c. Addison syndrome; Cushing syndrome d. Addison syndrome; Cushing disease

OBJ: 2

, and an excess is

.

ANS: B

Addison disease is the disease or condition caused by a deficiency of adrenocorticosteroids. Cushing syndrome is produced by an excess of adrenocorticosteroids. It is Addison disease and Cushing syndrome.

DIF: Recall OBJ: 3

REF: Uses (Medical Uses [Replacement]) | p. 190 TOP: NBDHE, 6.0. Pharmacology

22. Corticosteroids are mainly used in medicine and dentistry for treatment of which types of conditions? a. Hypertension b. Adult periodontitis c. Osteoporosis d. Inflammatory conditions ANS: D

The most extensive use is in the treatment of inflammatory and allergic conditions. The blood pressure of patients taking corticosteroids should be measured because these agents can exacerbate hypertension. Steroids have actions that can contribute to periodontal disease. Steroids can cause osteoporosis, which may reduce bony support for the teeth.

DIF: Comprehension REF: Uses (Medical Uses [Inflammatory/Allergy]) | p. 190 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

MULTIPLE RESPONSE 1. Inhibition of phospholipase A by steroids leads to decreased production of (Select all that apply.) a. neutrophils. b. prostaglandins. c. arachidonic acid. d. leukotrienes.

ANS: B, D

Steroids lead to decreased production of prostaglandins and leukotrienes from arachidonic acid. Use of steroids results in an increase in the concentration of neutrophils.

DIF: Application REF: Mechanism of Action | p. 188 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

2. Which of the following conditions may be exacerbated by corticosteroid use? (Select all that apply.)

a. b. c. d. e.

Hypertension Hypotension Congestive heart failure Glaucoma Osteoporosis

ANS: A, C, D, E

Corticosteroids can exacerbate hypertension and congestive heart failure by their mineralocorticoid effects of increasing circulatory volume. They can also directly increase intraocular pressure, and exacerbate glaucoma. Dental images may demonstrate osteoporosis in patients taking long-term adrenocorticosteroids. The blood pressure of patients taking corticosteroids should be measured because these agents can exacerbate hypertension. The more mineralocorticoid action, the more likely the agent is to raise blood pressure.

DIF: Application REF: Adverse Reactions (Impaired Wound Healing and Osteoporosis) (Ophthalmic Effects) (Electrolyte and Fluid Balance) | p. 189 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Levels of endogenous corticosteroids can increase tenfold in response to an especially stressful

stimulus.

ANS: T

The body can protect itself from a stressful episode by raising the circulating corticosteroid as much as ten times.

DIF: Recall REF: Classification | p. 187 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

2. The adverse effects of glucocorticoids are primarily an extension of their therapeutic actions.

ANS: T

The immunosuppressant and antiinflammatory actions of glucocorticoids not only serve therapeutic purposes, but also produce many of these agents’ most severe adverse effects.

DIF: Recall REF: Adverse Reactions | p. 188 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

3. Corticosteroids increase resistance to infection.

ANS: F

Corticosteroids decrease resistance to infection. They can also mask symptoms of infection because of their inflammatory action.

DIF: Recall OBJ: 3

REF: Adverse Reactions (Infections) | p. 189 TOP: NBDHE, 6.0. Pharmacology

4. Most dental patients taking steroids who are having normal dental treatment rendered do not need

additional corticosteroids.

ANS: T

Supplemental steroids may be required if the patient has severe dental fears or for major surgical procedures.

DIF: Recall REF: Dental Implications (Box 16.3: Management of Dental Patient Who Is Taking or Has Taken Corticosteroids) | p. 192 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 5. Adrenal crisis is a rare event in dentistry.

ANS: T

This is especially true for patients with secondary adrenal insufficiency, which is due to steroid used for certain medical conditions.

DIF: Recall OBJ: 5

REF: Dental Implications (Steroid Supplementation) | p. 193 TOP: NBDHE, 6.0. Pharmacology

Chapter 17: Drugs for the Treatment of Respiratory Disorders and Allergic Rhinitis Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Asthma is characterized by

airway obstruction and is associated with reduction in

airflow. a. reversible; inspiratory b. reversible; expiratory c. irreversible; inspiratory d. irreversible; expiratory ANS: B

Asthmatics trap air due to constriction of bronchiolar smooth muscle. A few hours later, inflammation occurs, resulting in an increase in secretions in the lungs and swelling in the bronchioles. Asthma is characterized by reversible airway obstruction and is associated with a reduction in expiratory airflow.

The reversible airway obstruction is in contrast to chronic obstructive pulmonary disease (COPD), which is characterized by irreversible airway obstruction, which occurs with either chronic bronchitis or emphysema.

DIF: Comprehension REF: Respiratory Diseases (Asthma) | p. 195 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Patients with

asthma experience symptoms less than two times a month, and the symptoms do not interfere with normal activity. a. intermittent b. mild persistent c. moderate persistent d. severe persistent

ANS: A

Intermittent asthma is characterized by the presence of symptoms less than two times a month, and the symptoms do not interfere with normal activity. Persistent asthma occurs anywhere from more than twice a week to all day long. Persistent asthma can cause minor limitations of normal activities, and severe persistent asthma can severely limit the patient’s normal activities.

DIF: Recall OBJ: 1

REF: Respiratory Diseases (Asthma) | p. 195 TOP: NBDHE, 6.0. Pharmacology

3. Asthma may be precipitated by (1) allergens, (2) exercise, (3) stress. a. 1, 2, 3 b. 1, 2 c. 1, 3 d. 2, 3 ANS: A

The dental health care worker should treat dental patients with asthma so that minimal stress is induced. Asthma may be precipitated by allergens, pollution, exercise, stress, or upper respiratory tract infection.

DIF: Recall OBJ: 1

REF: Respiratory Diseases (Asthma) | p. 195 TOP: NBDHE, 6.0. Pharmacology

4. In status asthmaticus, patients have persistent life-threatening a. tachycardia. b. stomach ulcers. c. bronchospasm. d. electrolyte imbalance.

ANS: C

Status asthmaticus is characterized by increased and progressive dyspnea, jugular venous pulsation, cyanosis, and pulsus paradoxus. Asthma causes more than 5000 deaths per year in the United States.

Death is more likely in persons over 45 years old. They are largely preventable and are often related to a delay in the delivery of appropriate medical care. Patients have persistent life-threatening bronchospasm in status asthmaticus despite drug therapy.

DIF: Comprehension REF: Respiratory Diseases (Asthma) | p. 195 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. Patients with asthma should bring their fast-acting

inhaler to be used prophylactically or in the management of an acute asthmatic attack in the dental office. a. -agonist b. 1-agonist c. 1-antagonist d. 2-agonist e. 2-antagonist ANS: D

The stimulation of 2-receptors results in smooth-muscle relaxation. Because the blood vessels of the skeletal muscle are innervated with 2-receptors, stimulation causes vasodilation. Relaxation of the smooth muscles of the bronchioles, also containing 2-receptors, results in bronchodilation. A fastacting 2-agonist should be available to manage an acute asthmatic attack in the dental office. Signs of asthma include shortness of breath and wheezing.

DIF: Recall OBJ: 1

REF: Respiratory Diseases (Asthma) | p. 195 TOP: NBDHE, 6.0. Pharmacology

6. Which of the following respiratory diseases is associated with irreversible airway obstruction? a. Asthma b. Chronic bronchitis c. Emphysema d. Both A and B e. Both B and C ANS: E

Chronic obstructive pulmonary disease (COPD) is characterized by irreversible airway obstruction, which occurs with either chronic bronchitis or emphysema. Asthma is characterized by reversible airway obstruction and is associated with reduction in expiratory airflow.

DIF: Comprehension REF: Respiratory Diseases (Chronic Obstructive Pulmonary Disease) | p. 196 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 7. Which of the following groups of medications are considered first-line treatment for chronic

obstructive pulmonary disease (COPD)? a. -Adrenergic agonists b. Antimuscarinics c. Methylxanthines d. Leukotriene (LT) antagonists ANS: B

Inhaled antimuscarinic drugs appear to inhibit vagally mediated reflexes by antagonizing the action of acetylcholine. This then causes bronchodilation. Ipratropium bromide (Atrovent) is a short-acting muscarinic antagonist agent available for oral inhalation for people with COPD. Antimuscarinics are considered first-line treatment for chronic bronchitis and emphysema, but -adrenergic agonists are also used to produce bronchodilation in these patients. In many instances, patients receive a combination metered-dose inhaler (MDI) with an antimuscarinic drug and a 2-adrenergic agonist.

DIF: Recall REF: Respiratory Diseases (Chronic Obstructive Pulmonary Disease) | p. 196 | Drugs Used to Treat Respiratory Diseases (Muscarinic Antagonists) | p. 202 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 8. The drive for ventilation is stimulated by a(n)

person. a. depression; carbon dioxide (PaCO2) b. elevation; carbon dioxide (PaCO2)

in the partial pressure of

in the normal

c. depression; oxygen (PaO2) d. elevation; oxygen (PaO2) ANS: B

The drive for ventilation is stimulated by a rise in carbon dioxide. Swimmers are told not to hyperventilate before swimming under water for this reason. In the average person, the drive for ventilation is stimulated by an elevation in PaCO2. The PaO2 can vary widely without stimulating ventilation in the normal patient.

DIF: Comprehension REF: Respiratory Diseases (Chronic Obstructive Pulmonary Disease) | p. 196 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 9. The ventilation of a patient with COPD is driven by a(n) a. increase in PaO2. b. decrease in PaO2. c. increase in PaCO2. d. decrease in PaCO2.

ANS: B

Patients with COPD respond to a decrease in the oxygen level rather than a rise in the carbon dioxide level. Patients with COPD experience a gradual rise in PaCO 2 over time. Because this mechanism becomes resistant to changes in PaCO2, a new stimulus emerges, the PaO2. The patient’s ventilation is then driven by a decrease in PaO2.

DIF: Comprehension REF: Respiratory Diseases (Chronic Obstructive Pulmonary Disease) | p. 196 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 10. If a patient with COPD is given oxygen and the PaO2 rises, the stimulant to breathing is a. markedly stimulated. b. slightly stimulated. c. slightly depressed. d. removed.

ANS: D

For patients with severe COPD, it is suggested that oxygen be limited to less than 3 L/min. The stimulant to breathing is removed if a patient with COPD is given oxygen and the PaO2 rises because the patient’s ventilation is driven by a decrease in PaO2. The possibility of inducing apnea exists.

DIF: Recall OBJ: 1

REF: Respiratory Diseases (Chronic Obstructive Pulmonary Disease) | p. 196 TOP: NBDHE, 6.0. Pharmacology

11. Which of the following statements represents the primary advantage of the use of metered-dose

inhalers (MDIs)? a. The inhaled dose can be accurately measured. b. They are difficult to use properly, and they can be abused. c. The onset of action is unpredictable. d. The bronchodilator effect is less than that of a comparable oral dose.

ANS: A

The inhaled dose can be accurately measured. MDIs are difficult to use properly (particularly for children) and they can be abused, with a resultant decrease in response. The onset of action is rapid and predictable (versus unpredictable response with orally administered agents). The bronchodilator effect is greater than a comparable oral dose.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Metered-Dose Inhalers) | p. 199 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 12. The first line of treatment for intermittent asthma is a a. short-acting 2-adrenergic agonist. b. long-acting 2-adrenergic agonist. c. corticosteroid. d. mast cell degranulation inhibitor. e. methylxanthine.

ANS: A

Recent studies have shown that the overuse of these agents results in airway hyper-responsiveness and a decrease in the lung’s response to them. These agents should be used primarily for the treatment of acute problems, not for the management of normal breathing function. A short-acting 2-adrenergic agonist is the first line of treatment for intermittent asthma. Short-acting 2-agonists are the drugs of choice for the emergency treatment of an acute asthma attack.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Sympathomimetic Agents [Short-Acting Beta2-Agonists]) | p.

200 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. Albuterol is a bronchodilator that can be administered via a metered-dose inhaler (MDI). It is

recommended in prophylactically treating (preventing) chronic asthma. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second statement is false. d. The first statement is false; the second statement is true.

ANS: C

Albuterol (ProAir HFA, Proventil HFA, Ventolin HFA, ProAir RespiClick, ProAir Digihaler), and levalbuterol (Xopenex HFA) are short-acting 2-adrenergic agonists. Inhaled corticosteroids are the most effective long-term treatment for control of symptoms in all patients with mild, moderate, or severe persistent asthma. Albuterol is a bronchodilator administered via inhaler. However, it is recommended to treat acute asthma attacks, not in the prevention of asthma. One major mistake that many asthmatics make is to rely on the albuterol inhaler and omit using the steroid inhaler.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Sympathomimetic Agents [Short-Acting Beta2-Agonists] [Table 17.2: US Food and Drug Administration-Approved Drugs Used to Manage Asthma]) | pp. 197-200 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

14. Which of the following drugs used to treat respiratory diseases carries a black box warning about a

higher risk of asthma-related deaths as a result of a high number of asthma-related deaths reported with salmeterol therapy during a clinical trial? a. Mast cell degranulation inhibitors b. Anti-immunoglobulin E (IgE) antibodies c. Short-acting 2-agonist d. Long-acting 2-agonist ANS: D

Long-acting 2-agonists are best administered in a fixed-dose combination in the same inhaler with an inhaled corticosteroid. Long-acting 2-agonists are combined with corticosteroid inhalers so that two different drugs, at lower doses, can be used to treat persistent asthma. Long-acting 2-agonists carry a black box warning.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Sympathomimetic Agents [Long-Acting Beta 2-Agonists]) | p. 201 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 15. Which of the following drugs is the most effective long-term treatment for control of symptoms in all

patients with mild, moderate, or severe persistent asthma? a. LT modifiers b. Cromolyn c. Long-acting 2-agonists d. Theophylline e. Corticosteroids ANS: E

Inhaled corticosteroids are the most effective. Most patients experience a positive response at relatively low doses. Randomized, controlled clinical trials have demonstrated that inhaled corticosteroids are more effective than LT modifiers, long-acting 2-agonists, cromolyn, or theophylline in improving pulmonary function, preventing symptoms and exacerbations, reducing the need for emergency room visits, and decreasing the number of asthma-related deaths.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Corticosteroids [Asthma]) | p. 201 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 16. Which one of the following drugs can result in oral candidiasis? a. Fluticasone b. Phenytoin c. Acetaminophen d. Metoprolol e. Omeprazole ANS: A

Fluticasone is a corticosteroid that is inhaled by patients with asthma and respiratory problems.

Corticosteroids are known to result in oral candidiasis; therefore, make sure the patient rinses after using his or her inhaler. Phenytoin is for seizures and can cause gingival hyperplasia. Acetaminophen is an analgesic. Metoprolol is a selective beta-blocker used to treat high blood pressure. Omeprazole is a proton-pump inhibitor used to treat ulcers and gastroesophageal reflux disease (GERD).

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Corticosteroids [Asthma]) | p. 201 | Drugs Used to Treat Respiratory Diseases (Corticosteroids [Asthma] [Table 17.2: US Food and Drug Administration-Approved Drugs Used to Manage Asthma]) | p. 198 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 17. Which one of the following recommendations would you not make to your patients with asthma? a. Bring your inhaler (albuterol) to the dental appointment. b. Rinse after using your corticosteroid inhaler. c. Avoid erythromycin. d. Avoid aspirin. e. Avoid acetaminophen.

ANS: E

Acetaminophen and weak narcotic analgesics are probably permissible for asthmatics. Definitely have all asthmatics bring their inhaler to the dental appointment and keep it within reach. Given that corticosteroids can promote the growth of oral Candida, patients should rinse with water after using the inhaler. If the patient is taking theophylline, then erythromycin can cause toxicity by inhibiting its metabolism and increasing theophylline’s blood levels. Aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and strong opioids should be avoided in patients with asthma.

DIF: Application REF: Dental Implications of the Respiratory Drugs (Box 17.1: Management of the Dental Patient With Asthma) | p. 203 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 18. Which of the following statements is true of leukotrienes (LTs)? a. LTs produce bronchodilation and decreased bronchial hyperreactivity. b. LTs are produced by cells of inflammation. c. LTs produce increased secretion of mucus and mucosal edema. d. Both A and B are true. e. Both B and C are true.

ANS: E

LTs are produced by cells of inflammation and produce increased mucus secretion and mucosal edema. LTs produce bronchoconstriction and increased bronchial hyperreactivity.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Leukotriene Modifiers) | p. 201 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 19. Leukotriene modifiers are used to manage patients with

corticosteroid inhibitors. a. emphysema b. asthma

that is not controlled by 2-agonists and

c. chronic bronchitis d. acute bronchitis ANS: B

Zafirlukast (Accolate) and montelukast (Singulair) are leukotriene receptor antagonists. They block the action of cysteinyl leukotrienes (LTRA). Zileuton (Zyflo) and zileuton, extended release (Zyflo CR) are leukotriene pathway synthesis inhibitors. They inhibit 5-lipoxygenase that catalyzes production of LT (LTD4 and LTE4). They are not as effective as the corticosteroid inhalers. Both are effective taken orally. Leukotriene modifiers manage asthma that is not controlled by 2-agonists and corticosteroid inhibitors.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Leukotriene Modifiers) | p. 201 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 20. Which of the following agents prevents the antigen-induced release of histamine from sensitized mast

cells? a. Leukotriene (LT) modifiers b. Corticosteroids c. Cromolyn d. Methylxanthines e. Anti-IgE antibodies ANS: C

Cromolyn prevents the release of histamine from sensitized mast cells, apparently by preventing the influx of calcium provoked by IgE antibody-antigen interaction on the mast cell. LT modifiers block the effects of the release of LTs. Corticosteroids reduce airway inflammation. Methylxanthines are direct smooth muscle relaxants. Anti-IgE antibodies prevent IgE from binding to mast cells and basophils, which prevents an inflammatory response.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Cromolyn) | p. 202 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 21. a. b. c. d. e.

is the least toxic of all asthma medications.

Omalizumab Cromolyn Theophylline Fluticasone Zileuton

ANS: B

The advantage of cromolyn is its safety. It may be used prophylactically by patients with chronic asthma or taken before exercise-induced asthma. Intranasal cromolyn (Nasalcrom) is available overthe-counter (OTC) for allergic rhinitis. Cromolyn is the least toxic asthma medication. It is currently available in a metered-dose form as in the other inhalation agents.

DIF: Recall OBJ: 2

REF: Drugs Used to Treat Respiratory Diseases (Cromolyn) | p. 202 TOP: NBDHE, 6.0. Pharmacology

22. Which of the following medications is used to treat persistent asthma and the bronchospasm associated

with chronic bronchitis and emphysema? a. Theophylline b. Ipratropium c. Omalizumab d. Cromolyn ANS: A

Theophylline is used to treat persistent asthma and the bronchospasm associated with chronic bronchitis and emphysema. Bronchodilation is the major therapeutic effect desired. Ipratropium is a short-acting anticholinergic available for oral inhalation for people with COPD. Omalizumab is the first in a new class of medications introduced to treat asthma due to allergens. Cromolyn is effective only for the prophylaxis of asthma and not for treatment of an acute attack.

DIF: Recall OBJ: 2

REF: Drugs Used to Treat Respiratory Diseases (Methylxanthines) | p. 202 TOP: NBDHE, 6.0. Pharmacology

23. A significant drug interaction occurs between theophylline and

that can result in toxic serum

levels of theophylline. a. aspirin b. erythromycin c. nifedipine d. clomiphene ANS: B

Side effects associated with the methylxanthines include central nervous system (CNS) stimulation, cardiac stimulation, increased gastric secretion, and diuresis. Patients often complain of nervousness and insomnia. Erythromycin can increase the serum levels of theophylline, and toxicity may result.

Patients on chronic theophylline may have blood levels drawn to determine if the dose they are taking is appropriate.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Methylxanthines) | p. 202 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 24. The drug of first choice for emphysema is a. albuterol. b. zileuton. c. theophylline. d. beclomethasone. e. ipratropium.

ANS: E

COPD occurs with emphysema. Ipratropium is the drug of choice for long-term management of COPD. Albuterol may be used along with ipratropium in some cases but is not the drug of first choice for emphysema. Theophylline may also be used in cases of emphysema. Zileuton is a leukotriene synthesis inhibitor that is a second-line asthma drug. Beclomethasone is a corticosteroid used in asthma.

DIF: Recall

REF: Drugs Used to Treat Respiratory Diseases (Muscarinic Antagonists) | p. 202 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 25. Which of the following statements is true of omalizumab (Xolair)? a. It is a recombinant humanized monoclonal antibody. b. It prevents IgE from binding to mast cells and basophils. c. It is administered by inhalation. d. Both A and B are true. e. Both B and C are true.

ANS: D

Omalizumab is the first in a new class of medications introduced to treat asthma caused by allergens. It is recombinant humanized monoclonal antibody that prevents IgE from binding to mast cells and basophils, thereby preventing the release of inflammatory mediators after allergen exposure.

Omalizumab is administered by subcutaneous injection every 2 to 4 weeks. Adverse reactions include pain and bruising at the injection site.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Anti-Immunoglobulin E Antibodies) | p. 202 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 26. Pseudoephedrine, agonist, is used systemically as a nasal decongestant. a. an -adrenergic b. a -adrenergic c. an -adrenergic and -adrenergic d. neither an -adrenergic nor a -adrenergic ANS: C

Pseudoephedrine is both an -adrenergic and a -adrenergic agonist and is used systemically as a nasal decongestant. The remaining choices are not correct regarding pseudoephedrine.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Agents Used to Manage Upper Respiratory Infections [Nasal Decongestants]) | p. 203 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27.

is a concern when administering local anesthetics with sulfiting agents as a preservative for the vasoconstrictor. a. Tardive dyskinesia b. Bronchoconstriction c. Tachycardia d. Emesis ANS: B

Sulfites are used in local anesthetic solutions to prevent oxidation of the vasoconstrictor. The group of people most susceptible to allergic reactions caused by sulfites includes the 9 to 11 million persons in the United States in whom asthma has been diagnosed. Sulfiting agents in local anesthetic agents with vasoconstrictor can lead to bronchoconstriction.

DIF: Recall REF: Dental Implications of the Respiratory Drugs (Box 17.1: Management of the Dental Patient With

Asthma) | p. 203

OBJ:

3

TOP:

NBDHE, 6.0. Pharmacology

28. Which of the following classes of antibodies is triggered when an allergen is inhaled in an individual

with a sensitized immune system? a. IgA b. IgD c. IgE d. IgG e. IgM ANS: C

The allergen triggers the response of the antibody immunoglobulin E (IgE). IgE is the key antibody in the pathogenesis of type I hypersensitivity reactions. The other choices do not represent the class of antibodies that is triggered when an allergen is inhaled in an individual with a sensitized immune system.

DIF: Recall REF: Allergic Rhinitis | p. 203 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

refers to agents that are H1-blockers.

29. The term a. histamine b. antihistamine c. adrenergic d. cholinergic ANS: B

Antihistamine refers to these agents. The dentist may prescribe, or the patient may self-medicate with, antihistamines before a dental procedure to reduce symptoms of hay fever and make it easier for the patient to breathe. First-generation H1 antihistamines have several pharmacologic effects, including antihistaminic, anticholinergic, and antiserogenic effects.

DIF: Recall REF: Allergic Rhinitis | p. 203 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

30. The primary advantage of second-generation H1 agents is that they are less likely to have which of the

following pharmacologic effects of first-generation H1 antihistamines? a. Antihistaminic b. Antiserotonergic c. Anticholinergic d. Sedative ANS: D

Second-generation H1 antihistamines are less likely to cause sedation because they penetrate poorly into the central nervous system. Sedation is the most common side effect associated with firstgeneration antihistamines, and it may be accompanied by dizziness, tinnitus, incoordination, blurred vision, and fatigue.

DIF: Recall OBJ: 4

REF: Allergic Rhinitis (Pharmacologic Effects) | p. 204 TOP: NBDHE, 6.0. Pharmacology

31. Which of the following common antihistamines produces the most sedation? a. Brompheniramine (Dimetane) b. Chlorpheniramine (Chlor-Trimeton) c. Diphenhydramine (Benadryl) d. Fexofenadine (Allegra) e. Loratadine (Claritin) ANS: C

Diphenhydramine (Benadryl) produces the highest level of sedation. The other choices do not produce the most sedation.

DIF: Comprehension REF: Allergic Rhinitis (Pharmacologic Effects [Table 17.6: Selected Oral Drugs for Allergic Rhinitis]) | p. 205 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 32. Antihistamines that are H1-antagonists are least effective at competitively blocking the effect of

histamine at which of the following sites? a. Nonvascular smooth muscle (bronchial) b. Vascular smooth muscle (vessels) c. Capillary permeability d. Nerve endings ANS: A

Because other autocoids are also released in an anaphylactic reaction, antihistamines are not effective in counteracting all the bronchoconstriction during that reaction. The antihistamines block the dilation of the vascular smooth muscle that histamine produces. By blocking capillary permeability produced by histamine, less tissue edema occurs from the transport of the serum into the intracellular spaces.

Antihistamines can suppress the itching and pain associated with this histamine-mediated reaction at the cutaneous nerve endings.

DIF: Application OBJ: 4

REF: Allergic Rhinitis (H1-Receptor Blocking Effects) | p. 204 TOP: NBDHE, 6.0. Pharmacology

33. Which of the following symptoms is the most common side effect associated with the older

antihistamines? (Please note: all are associated, but one is most common) a. Nausea b. Xerostomia c. Sedation d. Constipation ANS: C

Sedation is the most common side effect associated with the older antihistamines, and it may be accompanied by dizziness, tinnitus, incoordination, blurred vision, and fatigue. Patients who are given first-generation antihistamines should be warned against operating a motor vehicle or signing important documents. The gastrointestinal complaints commonly associated with the antihistamines include anorexia, nausea, vomiting, and constipation. Xerostomia is categorized as an anticholinergic adverse reaction.

DIF: Comprehension REF: Allergic Rhinitis (Central Nervous System Depression) | p. 204

OBJ: 4

TOP: NBDHE, 6.0. Pharmacology

34. Antihistamines such as loratadine (Claritin) are nonsedating because they a. stimulate the CNS. b. bind only to H2-receptors. c. are combined with decongestants that have CNS stimulant activity. d. do not cross the blood-brain barrier.

ANS: D

For an agent to cause drowsiness and sedation, it needs to penetrate the blood-brain barrier. The newer nonsedating H1-blockers, such as loratadine (Claritin), produce less sedation because they do not easily penetrate the brain. Loratadine does not enter the brain and does not stimulate the CNS. Loratadine is an H1-receptor antagonist, not H2. Loratadine is nonsedating, even when taken in the absence of stimulating decongestants.

DIF: Comprehension REF: Allergic Rhinitis (Central Nervous System Depression) | p. 204 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 35. Which of the following types of medication are considered first-line therapy for the treatment of

moderate to severe allergic rhinitis? a. Leukotriene modifiers b. Intranasal corticosteroids c. Mast cell stabilizers d. Intranasal decongestants ANS: B

Intranasal corticosteroids are very effective for the treatment of moderate to severe allergic rhinitis and are considered first-line therapy. They are used to control symptoms of rhinorrhea, itching, sneezing, and nasal congestion. Leukotriene modifiers are less effective than H1-antihistamines and intranasal corticosteroids. Mast cell stabilizers are less effective than intranasal corticosteroids. Intranasal decongestants should not be used for more than 3 to 5 days in order to avoid rebound congestion.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 205 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 36. Montelukast (Singulair) is a(n) a. intranasal corticosteroid. b. leukotriene modifier. c. intranasal anticholinergic drug. d. mast cell stabilizer. e. oral decongestant.

ANS: B

Montelukast (Singulair) is a leukotriene receptor antagonist that is approved for the treatment of seasonal and perennial allergic rhinitis. Cysteinyl leukotriene is released in the nasal mucosa during an allergic reaction causing nasal congestion. Montelukast is a leukotriene modifier that provides relief for sneezing, itching, discharge, and congestion.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 37. Montelukast is generally well tolerated. It is more effective than H 1-antihistamines and intranasal

corticosteroids. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: C

Montelukast is generally well tolerated; however, postmarketing reports of psychiatric symptoms and sleep disturbances. It is usually used as adjunct therapy to H1-antihistamines and intranasal corticosteroids. Montelukast is generally well tolerated. It is less effective than H 1-antihistamines and intranasal corticosteroids.

DIF: Application REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 38. Which of the following drugs is a mast cell stabilizer? a. Ipratropium bromide (Atrovent) b. Montelukast (Singulair) c. Cromolyn sodium (Nasalcrom) d. Azelastine (Astelin) ANS: C

Cromolyn sodium (Nasalcrom) is a mast cell stabilizer. It prevents allergic rhinitis symptoms when taken before the onset of triggers. The remaining choices are not mast cell stabilizers. Ipratropium bromide is an anticholinergic, montelukast is a leukotriene antagonist, and azelastine is an H 1-receptor inhibitor.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 39. Which of the following is the mechanism of action of cromolyn sodium (Nasalcrom)? a. Inhibits mast cell degranulation b. Blocks acetylcholine receptors c. Stimulates alpha1 adrenergic receptors d. Stimulates cholinergic receptors ANS: A

Cromolyn sodium inhibits mast cell degranulation and mediator release when given before allergen exposure. It must be used four times a day. The remaining choices do not describe the mechanism of action of cromolyn.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ:

6

TOP: NBDHE, 6.0. Pharmacology

40. Ipratropium bromide (Atrovent) is an intranasal _ a. adrenergic b. cholinergic c. antiadrenergic d. anticholinergic

drug.

ANS: D

Ipratropium bromide is an intranasal anticholinergic drug. It is poorly absorbed systemically and does not readily cross the blood-brain barrier. It can cause dry nose and mouth, epistaxis, and pharyngeal irritation. Adrenergic and anticholinergic medications produce dryness. Ipratropium bromide is an anticholinergic.

DIF: Application REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 41. Which of the following types of drugs is known to increase intraocular pressure if inadvertently placed

in the eye? a. Mast cell stabilizer b. Antihistamine c. Intranasal anticholinergic d. Leukotriene modifier ANS: C

An intranasal anticholinergic such as ipratropium bromide should be used with caution in patients with glaucoma. Ipratropium bromide, a quaternary amine intranasal anticholinergic drug, can increase intraocular pressure if placed in the eye.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 42. Oral decongestants are alpha-adrenergic antagonists that cause a vasoconstriction of the nasal mucosa.

Intranasal decongestants are an alternative to oral decongestants that are less likely to cause systemic adverse effects. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second statement is false. d. The first statement is false; the second statement is true.

ANS: D

Pseudoephedrine and phenylephrine are thought to stimulate alpha1 adrenergic receptors on the venous sinusoids. Intranasal decongestants are alternatives to oral decongestants as they are less likely to cause systemic adverse effects. They can, however, cause stinging, burning, sneezing, and dry throat or nose. Oral decongestants are alpha-adrenergic agonists. Alpha effects cause peripheral vasoconstriction.

DIF: Comprehension

REF: Allergic Rhinitis (Anticholinergic Effects [Decongestants]) | p. 206 | Allergic Rhinitis (Anticholinergic Effects [Decongestants]) | p. 206 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 43. Why should intranasal decongestants only be used for 3 to 5 days? a. They produce systemic toxicity. b. They can cause rebound congestion. c. They will start to cause systemic autocoid effects. d. They will produce xerostomia.

ANS: B

Rebound congestion is treated by discontinuing the intranasal decongestant and then having the patient use an intranasal corticosteroid or possibly a short course of oral steroids to help control symptoms.

Intranasal decongestants should not be used for more than 3 to 5 days to avoid rebound congestion.

DIF: Comprehension REF: Allergic Rhinitis (Anticholinergic Effects [Decongestants]) | p. 206 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 44. Which type of medication is recommended for the treatment of intermittent asthma? a. Inhaled corticosteroid b. Leukotriene modifier c. Short-acting 2-agonist d. Long-acting 2-agonist ANS: C

Patients with intermittent asthma have symptoms less than two times a month and the symptoms do not interfere with normal activity. Low-dose inhaled corticosteroid is recommended for moderate persistent asthma, and medium-dose inhaled corticosteroid is recommended for severe persistent asthma. A leukotriene modifier is recommended for mild persistent, moderate persistent, or severe persistent asthma. A long-acting 2-agonist is recommended for moderate persistent or severe persistent asthma.

DIF: Comprehension REF: Respiratory Diseases (Asthma [Table 17.1: Treatment of Asthma]) | p. 196 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 45. A high-dose inhaled corticosteroid is recommended for which form of asthma? a. Intermittent b. Mild persistent c. Moderate persistent d. Severe persistent ANS: D

A high-dose corticosteroid is recommended for treatment of severe persistent asthma. A short-acting 2-agonist is recommended for intermittent asthma. Low-dose inhaled corticosteroid is recommended for mild persistent asthma. Either low-dose inhaled corticosteroid and a long-acting 2-agonist or medium-dose inhaled corticosteroid is recommended for moderate persistent asthma.

DIF: Comprehension

REF: Respiratory Diseases (Asthma [Table 17.1: Treatment of Asthma]) | p. 196 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 46. Asthma is characterized by

airway obstruction, and chronic bronchitis by

airway obstruction. a. reversible; reversible b. reversible; irreversible c. irreversible; reversible d. irreversible; irreversible ANS: B

Asthma is characterized by reversible airway obstruction and chronic bronchitis is characterized by irreversible airway obstruction. Asthma is characterized by reversible airway obstruction. There have been many famous Olympic champions who were asthmatic. Chronic bronchitis and emphysema are forms of chronic obstructive pulmonary disease that are characterized by irreversible airway obstruction.

DIF: Comprehension REF: Respiratory Diseases (Asthma) | p. 195 | Respiratory Diseases (Chronic Obstructive Pulmonary Disease) | p. 196 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 47. Which respiratory disease is characterized by destruction of lung alveoli? a. Asthma b. Upper respiratory tract infection c. Chronic bronchitis d. Emphysema ANS: D

Emphysema is characterized by alveolar destruction with air space enlargement and airway collapse.

Asthma is characterized by inflammation and swelling in the bronchioles. Patients with upper respiratory tract infections have inflammation and swelling as well. Chronic bronchitis is a result of chronic inflammation of the airways and excessive sputum production.

DIF: Comprehension REF: Respiratory Diseases (Chronic Obstructive Pulmonary Disease) | p. 196 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 48. Adrenergic agonists produce bronchodilation by stimulating which type of receptors? a. Alpha b. Beta-1 c. Beta-2 d. Neuromuscular junction ANS: C

With the development of selective 2-agonists, bronchodilation with fewer cardiac side effects can be achieved. Stimulation of alpha receptors causes peripheral vasoconstriction. Stimulation of 1receptors causes an increase in cardiac output. Stimulation of neuromuscular junction receptors causes muscle movement.

DIF: Comprehension

REF: Drugs Used to Treat Respiratory Diseases (Sympathomimetic Agents) | p. 199 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 49. Which type of drug is used in conjunction with low-dose corticosteroids to treat patients with

persistent asthma that is not well controlled with low-dose inhaled corticosteroids? a. Corticosteroids b. Leukotriene modifiers c. Long-acting 2-agonists d. Mast cell degranulation inhibitors e. Anti-interleukin-5 antibodies ANS: C

Long-acting 2-agonists improve lung function, decrease symptoms, and reduce exacerbations of asthma and rescue uses of short-acting 2-agonists. Inhaled corticosteroids are used with long-acting 2-agonists for patients with persistent asthma for whom the corticosteroids alone are not working well.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Sympathomimetic Agents [Long-Acting Beta 2-Agonists]) | p. 201 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 50. Long-acting 2-agonists are recommended as monotherapy for asthma. Long-acting 2-agonists may

be recommended as monotherapy for patients with chronic obstructive pulmonary disease (COPD) who have moderate to severe airflow obstruction. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: D

Long-acting 2-agonists are used in conjunction with low-dose corticosteroids to treat patients with persistent asthma not well controlled with low-dose inhaled corticosteroids. Long-acting 2-agonists improve lung function and quality of life and lower exacerbation rates in patients with COPD. Longacting 2-agonists are not recommended as monotherapy for asthma; however, they may be recommended as monotherapy for patients with COPD. DIF: Application REF: Drugs Used to Treat Respiratory Diseases (Sympathomimetic Agents [Long-Acting Beta 2-Agonists]) | pp. 200-201 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 51. Which is an interleukin-5 antibody antagonist? a. Montelukast (Singulair) b. Mepolizumab (Nucala) c. Albuterol (Proventil HFA) d. Prednisone (Deltasone) e. Omalizumab (Xolair) ANS: B

Mepolizumab (Nucala) and reslizumab (Cinqair) are the first in a new class of drugs approved by the FDA to treat severe asthma in patients with elevated eosinophil levels. Montelukast (Singular) is a leukotriene modifier, albuterol (Proventil HFA) is a short-acting 2-adrenergic agonist, prednisone (Deltasone) is an oral corticosteroid, and omalizumab (Xolair) is an anti-IgE antibody.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Interleukin-5 Antibody Antagonists) | p. 202 | Respiratory Diseases (Chronic Obstructive Pulmonary Disease [Table 17.2: US Food and Drug Administration-Approved Drugs Used to Manage Asthma]) | p. 198 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 52. How are the interleukin-5 antibody antagonists administered to the patient? a. Inhaler b. Injection c. Oral administration with a tablet d. Oral administration with a liquid ANS: B

Mepolizumab (Nucala) is administered subcutaneously every 4 weeks. Reslizumab (Cinquair) is administered intravenously every 4 weeks. The interleukin-5 antibody antagonists are administered by injection. Cinqair is administered in a health care setting due to the risk of anaphylaxis.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Interleukin-5 Antibody Antagonists) | p. 202 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 53. Nasal decongestants are a. alpha-adrenergic agonists. b. alpha-adrenergic antagonists. c. beta-adrenergic agonists. d. beta-adrenergic antagonists.

ANS: A

They act by constricting blood vessels of the nasal mucous membranes. Alpha-adrenergic agonists cause peripheral vasoconstriction. Beta-1 agonists cause an increase in cardiac output. Beta-2 agonists cause relaxation of alveolar smooth muscle in the bronchioles.

DIF: Comprehension REF: Drugs Used to Treat Respiratory Diseases (Agents Used to Manage Upper Respiratory Infections [Nasal Decongestants]) | p. 202 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 54. Why is phenylephrine being used in many over-the-counter (OTC) oral decongestant products instead

of pseudoephedrine? a. Phenylephrine is much less costly than pseudoephedrine. b. Pseudoephedrine is used to make methamphetamine. c. Pseudoephedrine is derived from morphine and is a narcotic. d. Phenylephrine is more effective than pseudoephedrine.

ANS: B

Pseudoephedrine is one of the ingredients used to make methamphetamine. Phenylephrine, though less effective than pseudoephedrine, is not in many OTC oral decongestant products due to legal restrictions placed on the sale of pseudoephedrine.

DIF: Application OBJ: 7

REF: Allergic Rhinitis (Anticholinergic Effects [Decongestants]) | p. 206 TOP: NBDHE, 6.0. Pharmacology

55. Dupilumab (Dupixent) belong to which category of drugs used to treat respiratory diseases? a. Interleukin-4 receptor alpha antibody antagonist b. Interleukin-5 antibody antagonist c. Muscarinic antagonist d. Corticosteroid ANS: A

Dupilumab (Dupixent), the first in a new class of drugs, is an interleukin-4 receptor alpha subunit antagonist that inhibits interleukin-4 and interleukin-13 signaling and is approved for add-on maintenance treatment of moderate to severe asthma with an eosinophilic phenotype or oral corticosteroid-dependent asthma in persons 12 years of age or older.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Interleukin-4 Alpha Antibody Antagonist) | p. 202 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Histamine is released by which of the following types of white blood cells? (Select all that apply.) a. Polymorphonuclear leukocytes (PMNs) b. Mast cells c. Basophils d. Macrophages ANS: B, C

An allergen triggers the response of the antibody immunoglobulin E (IgE), which binds to mast cells and basophils containing histamine. The release of histamine causes itchy, watery eyes and runny noses. Histamine is not released by the other types of white blood cells.

DIF: Recall REF: Allergic Rhinitis | p. 203 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

2. Which of the following are sources of seasonal allergic rhinitis rather than perennial allergic rhinitis?

(Select all that apply.) a. Pollen from flowers b. Pollen from trees c. House dust d. Animal dander ANS: A, B

Seasonal allergic rhinitis is usually caused by pollen from trees, grass, and flowers and lasts for several weeks to months. The most effective method of treating allergic rhinitis is to eliminate the source of the allergen. It this is not possible then medication therapy is necessary. Perennial allergic rhinitis is a result of sensitivity to different allergens such as house dust or animal dander and lasts throughout the year.

DIF: Comprehension REF: Allergic Rhinitis | p. 203 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 3. Oral decongestants should be used with caution in patients with (Select all that apply.) a. cardiovascular disease. b. hypertension. c. diabetes. d. hyperthyroidism. e. closed-angle glaucoma.

ANS: A, B, C, D, E

The most common adverse effects associated with oral decongestants include insomnia, excitability, headache, nervousness, anorexia, palpitations, and tachycardia. Other adverse effects include arrhythmias, hypertension, nausea, vomiting, and urinary retention. All of the above choices are correct.

DIF: Comprehension REF: Allergic Rhinitis (Anticholinergic Effects [Decongestants]) | p. 206 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Researchers have suggested that oxygen be limited to less than 3 L/min for patients with severe

COPD. ANS: T

Other literature recommends that oxygen by nasal cannula be used during a dental appointment for patients with severe COPD, especially if pain or stress is anticipated.

DIF: Recall OBJ: 1

REF: Respiratory Diseases (Chronic Obstructive Pulmonary Disease) | p. 196 TOP: NBDHE, 6.0. Pharmacology

2. A spacer is often placed between the metered-dose inhaler and the mouth to decrease the amount of

drug delivered to the lungs.

ANS: F

The spacer increases the amount of drug delivered to the lungs.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Metered-Dose Inhalers) | p. 199 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 3. Nonchlorinated hydrofluoroalkane (HFA) propellants do not deplete the ozone layer.

ANS: T

Chlorofluorocarbons (CFCs), which have ozone-depleting properties, have been phased out as propellants in metered-dose inhalers (MDIs). They have been replaced by the nonchlorinated HFA propellants that do not deplete the ozone layer.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Metered-Dose Inhalers) | p. 199 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. The first line of treatment for intermittent asthma is a short-acting 2-agonist.

ANS: T

The short-acting 2-agonists are used for the emergency treatment of an asthma attack, as intermittent therapy, and for the prevention of exercise-induced asthma.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Sympathomimetic Agents [Short-Acting Beta2-Agonists]) | p.

200 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 5. Orally inhaled corticosteroids produce an immediate benefit in an acute asthma attack.

ANS: F

Although the steroids produce no immediate benefit in an acute asthmatic attack, they hasten recovery and decrease morbidity in these patients.

DIF: Recall REF: Drugs Used to Treat Respiratory Diseases (Corticosteroids [Asthma]) | p. 201 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. Allergic rhinitis is primarily associated with immunoglobulin A. ANS: F

Allergic rhinitis is associated with immunoglobulin E. The allergen triggers the response of the antibody immunoglobulin E (IgE), which binds to mast cells and basophils containing histamine.

DIF: Recall REF: Allergic Rhinitis | p. 203 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

7. Antihistamines may be used to treat a mild allergic reaction.

ANS: T

A mild allergic reaction to a drug may be treated with antihistamines in the dental office. Epinephrine should be used if the allergic reaction is severe.

DIF: Recall REF: Allergic Rhinitis | p. 204 TOP: NBDHE, 6.0. Pharmacology

OBJ: 4

8. Second-generation antihistamines are more likely to cause sedation than first-generation

antihistamines.

ANS: F

Second-generation H1 antihistamines penetrate poorly into the central nervous system and are less likely to cause sedation than first-generation antihistamines.

DIF: Recall OBJ: 4

REF: Allergic Rhinitis (Pharmacologic Effects) | p. 204 TOP: NBDHE, 6.0. Pharmacology

9. Sedation with first-generation antihistamines is additive with that caused by other CNS depressant

drugs.

ANS: T

Patients who are given first-generation antihistamines should be warned against operating a motor vehicle or signing important documents.

DIF: Recall OBJ: 4

REF: Allergic Rhinitis (Central Nervous System Depression) | p. 204 TOP: NBDHE, 6.0. Pharmacology

10. The first-generation H1 antihistamines have varying cholinergic effects.

ANS: F

H1 antihistamines have anticholinergic effects. Anticholinergic effects lead to xerostomia, which can result in an increased caries rate in patients taking antihistamines.

DIF: Recall OBJ: 4

REF: Allergic Rhinitis (Anticholinergic Effects) | pp. 204-205 TOP: NBDHE, 6.0. Pharmacology

11. Intranasal corticosteroids are considered first-line therapy for treating moderate to severe allergic

rhinitis.

ANS: T

Intranasal corticosteroids are very effective for the treatment of moderate to severe allergic rhinitis and are considered first-line therapy.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 205 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 12. Montelukast (Singulair) has been associated with postmarketing reports of psychiatric symptoms.

ANS: T

Montelukast is generally well tolerated; however, there are postmarketing reports of psychiatric symptoms and sleep disturbances.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 13. Cromolyn sodium works by blocking acetylcholine receptors.

ANS: F

Cromolyn sodium inhibits mast cell degranulation.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 14. Ipratropium bromide should be used with caution in patients with glaucoma.

ANS: T

It can increase intraocular pressure if inadvertently placed in the eye.

DIF: Recall REF: Allergic Rhinitis (Anticholinergic Effects [Adverse Reactions of Intranasal Dose Form]) | p. 206 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology

Chapter 18: Drugs for the Treatment of Diabetes Mellitus Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which of the following pancreatic hormones promotes fuel mobilization? a. Insulin b. Glucagon c. Islet amyloid polypeptide (IAPP; amylin) d. Pancreatic peptide ANS: B

Glucagon promotes fuel mobilization. Insulin promotes fuel storage. The functions of IAPP (amylin) and pancreatic peptide have not yet been elucidated.

DIF: Recall REF: Pancreatic Hormones | p. 208 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. More and more cases of type II diabetes are being reported in persons younger than 20 years because

of a. b. c. d.

an increased incidence of autoimmune disorders. a much more sedentary lifestyle and lack of exercise. illicit use of legal drugs. environmental changes and global warming.

ANS: B

Fast foods, video games, and television have replaced physical activity, and obesity, a major risk factor for developing type II diabetes, is on the rise. More and more cases of type II diabetes in young persons are being attributed to a much more sedentary lifestyle and lack of exercise.

DIF: Comprehension REF: Diabetes Mellitus (Types of Diabetes [Type 2]) | p. 208 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. Insulin resistance develops because of prolonged a. hyperglycemia; hyperinsulinemia b. hyperglycemia; hypoinsulinemia c. hypoglycemia; hyperinsulinemia d. hypoglycemia; hypoinsulinemia

and resulting

_.

ANS: A

Tissue insensitivity to insulin, a deficiency of the pancreas’s response to glucose, and obesity result in impaired insulin action. In the presence of hyperglycemia, the resistance of the tissues to insulin and the impaired  cells’ response are exaggerated. Hyperglycemia and resulting hyperinsulinemia lead to insulin resistance.

DIF: Recall OBJ: 1

REF: Diabetes Mellitus (Types of Diabetes [Type 2]) | p. 208 TOP: NBDHE, 6.0. Pharmacology

4. Type I and type II diabetics are at greater risk for caries. This risk is attributed to the higher

concentration of glucose in their saliva. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second statement is false. d. The first statement is false; the second statement is true.

ANS: C

The increased risk that a diabetic has for caries is due to xerostomia. A decrease in salivary flow can lead to mouth ulcers, inflamed tongue or mucosal tissues, and tooth deterioration. The complications of xerostomia are a result of the lack of its normal functions: lubricating, cleansing, regulating pH, destroying microorganisms and their products, and maintaining the integrity of oral structures.

Uncontrolled diabetes produces a pronounced susceptibility to dental caries, which is caused mainly by decreased salivary flow (xerostomia) related to fluid loss. The loss is secondary to an increase in urination that occurs because of poor utilization of carbohydrates and the glucose that is excreted via the kidneys (water follows glucose).

DIF: Application OBJ: 2

REF: Diabetes Mellitus (Dental Implications of Diabetes) | p. 209 TOP: NBDHE, 6.0. Pharmacology

5. All of the following are likely reasons why diabetics have a higher incidence of periodontal disease

except which one? a. Enhanced collagenase activity b. Loss of capillary basement membrane integrity c. Changes in glucose tolerance factor d. Microangiopathy of the tissues e. Altered polymorphonuclear leukocyte (PMN) function ANS: B

Diabetes causes a thickening of the capillary basement membrane, not a decrease in its integrity, which may compromise the transport and exchange functions of the capillaries. Enhanced collagenase activity will enhance the breakdown of connective tissue. Changes in glucose tolerance factor increase glucose levels. Microangiopathy of the tissues impairs circulation. Altered PMN function decreases the innate immune response. All of these are considered candidates for the etiology of diabetes-induced periodontal disease.

DIF: Comprehension REF: Diabetes Mellitus (Dental Implications of Diabetes [Periodontal Disease]) | p. 210 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. Which of the following statements is true concerning oral surgical procedures for the adult patient with

diabetes? a. The procedure should be performed before breakfast, and the patient should have taken regular diabetes medication. b. The procedures should be performed 1 1/2 to 2 hours after the patient has eaten a normal breakfast and has taken regular antidiabetes medication. c. The procedure should be performed after lunch, and the patient has taken regular diabetes medication. d. The procedure should be performed after lunch, and the patient should skip regular diabetes medication.

ANS: B

After surgery, the patient should receive an adequate caloric intake to prevent hypoglycemia. With general anesthesia, patients are often told to eat nothing by mouth and should take one half of their usual dose of insulin and receive intravenous 5% glucose in distilled water. The patient should eat a normal breakfast and take the regular antidiabetes medication prior to the procedure.

DIF: Comprehension REF: Diabetes Mellitus (Dental Implications of Diabetes [Issues in Dental Care]) | p. 210 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 7. Which of the following statements is true regarding systemic complications of diabetes? a. Hypolipidemia is common in patients with diabetes. b. Neuropathy is a complication of diabetes. c. Gangrene can occur in peripheral extremities. d. Both A and B are true. e. Both B and C are true.

ANS: E

Neuropathy is a complication of diabetes. It leads to reduced and sometimes absent feelings, especially in the lower extremities. Gangrene can occur in peripheral extremities, especially the feet and legs.

This occurs because of the deficiencies of diabetes, depressed immunity, less effective white blood cells, microvascular changes, and neuropathy. Hyperlipidemia and atherosclerosis are more common in these patients.

DIF: Comprehension REF: Diabetes Mellitus (Systemic Complications of Diabetes [Neuropathy]) | p. 211| Diabetes Mellitus (Systemic Complications of Diabetes [Infections]) | p. 211 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

8. Diabetic gastroparesis can be treated with a. amitriptyline. b. carbamazepine. c. ranitidine. d. metoclopramide.

ANS: D

Diabetic gastroparesis is atony of the gastrointestinal (GI) tract and is a consequence of diabetic neuropathy. It is treated with metoclopramide, which increases gastric motility. Amitriptyline is a tricyclic antidepressant. Carbamazepine is an antiepileptic drug. Ranitidine is an H2-receptor antagonist.

DIF: Recall REF: Diabetes Mellitus (Systemic Complications of Diabetes [Neuropathy]) | p. 211 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Contributing factors to gangrene in the extremities of diabetic patients include a. poor eyesight. b. poor circulation. c. reduced sensation in the extremities. d. All of the above. e. None of the above.

ANS: D

Poor eyesight and reduced sensation in the extremities increase the risk of injury that can lead to infection. Poor circulation makes it more difficult for the immune system and systemic drug therapy to reach the site of infection. All of the choices contribute to gangrene in the extremities of diabetic patients.

DIF: Application REF: Diabetes Mellitus (Systemic Complications of Diabetes [Infections]) | p. 211 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 10. Which of the following choices is recommended for the treatment of hypoglycemia if the patient is

unconscious and lacks a swallowing reflex? a. Fruit juice b. Cake icing c. Intravenous dextrose (50%) d. Glucose gel ANS: C

Intravenous dextrose (50%) is the treatment of choice for hypoglycemia if the patient is unconscious and lacks a swallowing reflex. Intravenous glucose fluids and glucagon can be administered. When the patient is awake in the early stages of hypoglycemia, the treatment consists of any of the following: fruit juice, cake icing, glucose gel, or soluble carbohydrates.

DIF: Recall OBJ: 6

REF: Treatment of Hypoglycemia | p. 218 TOP: NBDHE, 6.0. Pharmacology

11. The primary goal of treating diabetes is to maintain hemoglobin A1C levels a. at zero. b. as close to normal as possible (<7%). c. at a level of 40%. d. as high as possible.

ANS: B

An abundance of conclusive evidence from long-term, randomized clinical trials has proven that maintaining hemoglobin A1C levels as close to the normal range decreases the incidence and progression of microvascular complications of type 2 diabetes. For every percentage point drop in hemoglobin A1C decreases the risk of microvascular complications by 40%. The American Diabetes Association Standards of Medical Care in Diabetes recommends a hemoglobin A1C level <7% in order to reduce the incidence and progression of microvascular and macrovascular complication in patients with both type 1 and type 2 diabetes.

DIF: Comprehension REF: Diabetes Mellitus (Goals of Therapy) | p. 211 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 12. Insulin is usually administered a. orally. b. by subcutaneous injection. c. by intramuscular injection. d. by intravenous injection.

ANS: B

The major differences among the currently used types of insulin are their onset and duration of action.

Insulin is usually administered by subcutaneous injection. Its large molecular size prevents it from being absorbed from the GI tract.

DIF: Recall OBJ: 3

REF: Drugs to Manage Diabetes (Insulins) | p. 212 TOP: NBDHE, 6.0. Pharmacology

13. Human insulin is made from pork insulin by a. recombinant DNA synthesis. b. gene splicing in Escherichia coli. c. transpeptidation. d. transamination. e. glycosylation.

ANS: C

Pig insulin has only two amino acids that are different from those in human insulin. The protein can be converted by transpeptidation. Recombinant DNA synthesis and gene splicing in E. coli refer to the same process, which is the process for synthesizing human insulin from scratch. Transamination and glycosylation are two biochemical processes that are not used in making human insulin from pork insulin.

DIF: Recall OBJ: 3

REF: Drugs to Manage Diabetes (Insulins) | p. 212 TOP: NBDHE, 6.0. Pharmacology

14. Which form of insulin has a faster onset of action as a consequence of exchanging two amino acids in

the structure of human insulin? a. Pork insulin b. NPH insulin c. Prompt zinc insulin d. Lispro insulin e. Protamine zinc insulin ANS: D

Lispro, a new insulin, is made by exchanging two amino acids in the structure of human insulin. This change results in an insulin with a faster onset of action. Pork insulin differs from human insulin by two amino acids, but it does not have the characteristics of lispro. The other choices have the same peptide sequence as human insulin but are complexed with different ingredients to alter the onset and duration properties of the molecule.

DIF: Recall OBJ: 3

REF: Drugs to Manage Diabetes (Insulins) | p. 212 TOP: NBDHE, 6.0. Pharmacology

15. The most common adverse reaction associated with any insulin product is a. hypoglycemia. b. hyperglycemia. c. intestinal stasis. d. bradycardia.

ANS: A

Besides hypoglycemia, inhaled insulin can cause shortness of breath, dry mouth, and cough. The dental health care worker should be most concerned about a hypoglycemic reaction in the dental patient with diabetes who takes insulin. This reaction can be caused by an unintentional overdose of insulin, failure to eat, or increased exercise or stress.

DIF: Recall OBJ: 3

REF: Drugs to Manage Diabetes (Insulins) | p. 212 TOP: NBDHE, 6.0. Pharmacology

16. Which of the following symptoms of hypoglycemia can be explained by glucose deprivation of the

brain rather than the adrenal glands: (1) blurred vision, (2) incoherent speech, (3) sweating, (4) tachycardia? a. 1, 2, 3, 4 b. 1, 2, 3 c. 1, 2 d. 3, 4 ANS: C

Symptoms of hypoglycemia caused by glucose deprivation of the brain include headache, blurred vision, mental confusion, incoherent speech, and (eventually) coma, convulsions, and death.

Symptoms of hypoglycemia that can be explained by an increased release of epinephrine from the adrenals include sweating, weakness, nausea, and tachycardia.

DIF: Comprehension REF: Drugs to Manage Diabetes (Insulins) | p. 212 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

17. Which of the following statements is true of metformin? a. It is a member of the -glucosidase inhibitor group of antidiabetic agents. b. It lowers blood glucose but, used alone, does not produce hypoglycemia. c. It decreases hepatic and peripheral insulin sensitivity, resulting in increased hepatic

glucose production. d. Lactic acidosis is a common, but benign side effect.

ANS: B

Metformin (Glucophage) lowers blood glucose but, used alone, does not produce hypoglycemia.

Metformin is a member of the biguanide group of antidiabetic agents. It increases hepatic and peripheral insulin sensitivity, resulting in decreased hepatic glucose production. It also increases peripheral skeletal muscle glucose uptake. Lactic acidosis, its most serious side effect, is rare.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Biguanides]) | p. 213 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 18. Which oral antidiabetic agent produces lactic acidosis as a significant adverse effect? a. Tolbutamide b. Metformin c. Repaglinide d. Acarbose e. Pioglitazone ANS: B

The biguanides, such as metformin, can cause lactic acidosis as a side effect. Metformin is contraindicated in patients who have these conditions or are fasting. Tolbutamide (Orinase) is a sulfonylurea, repaglinide (Prandin) is a meglitinide, acarbose is an -glucosidase inhibitor, and pioglitazone (Actos) is a thiazolidinedione.

DIF: Comprehension REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Biguanides]) | p. 214 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 19. Adverse reactions to metformin occur primarily in the a. pancreas. b. GI tract. c. oral cavity. d. cardiovascular system.

ANS: B

Lactic acidosis, the most serious side effect with metformin, is rare. Predisposing factors to lactic acidosis include alcoholism, binge drinking, and renal or hepatic dysfunction. Adverse reactions are primarily related to the GI tract (30%) and include anorexia, dyspepsia, flatulence, nausea, and vomiting. It can produce headache and interfere with vitamin B12 absorption. It accumulates in renal and hepatic impairment.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Biguanides]) | p. 214 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

20. The mechanism of action of the sulfonylureas includes

of the release of insulin from the beta cells of the pancreas, of glucose from the liver and serum glucagon levels, and a(n) in the sensitivity of the target tissues to insulin. a. stimulation; increase; increase b. stimulation; increase; reduction c. stimulation; reduction; increase d. stimulation; reduction; reduction e. inhibition; reduction; reduction ANS: C

For many years, the sulfonylureas were the only orally active agents used to manage diabetes. Secondgeneration sulfonylureas have replaced first-generation sulfonylureas because they are less toxic and easier to dose than first-generation sulfonylureas. The mechanism of action of sulfonylureas includes stimulation of the release of insulin from the beta cells of the pancreas, reduction of glucose from the liver and serum glucagon levels, and an increase in the sensitivity of the target tissues to insulin.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Sulfonylureas]) | p. 217 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 21. Which of the following types of medications can react with sulfonylureas to produce a decrease in

serum glucose levels? a. Penicillin b. Methotrexate c. Aspirin d. Mepivacaine ANS: C

The interaction between sulfonylureas and aspirin is not clinically significant unless the diabetic patient is especially brittle. Brittle diabetes means the diabetes is difficult to control. Aspirin can interact with sulfonylureas to produce a decrease in serum glucose levels.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Sulfonylureas]) | p. 217 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 22. Which of the following statements is the mechanism of action of nonsulfonylurea secretagogues such

as repaglinide (Prandin) and nateglinide (Starlix)? a. They are competitive, reversible inhibitors of GI tract enzymes: intestinal aglucosidase and pancreatic á-amylase. b. They increase the insulin sensitivity of adipose tissue, skeletal muscle, and the liver. c. They increase hepatic and peripheral insulin sensitivity, resulting in decreased hepatic glucose production. d. They bind to adenosine triphosphate (ATP)-sensitive potassium channels on beta cells and increase insulin resistance.

ANS: D

Nonsulfonylurea secretagogues, such as repaglinide (Prandin) and nateglinide (Starlix), bind to ATPsensitive potassium channels on beta cells and increase insulin resistance. -glucosidase inhibitors are competitive, reversible inhibitors of GI tract enzymes: intestinal -glucosidase and pancreatic amylase. Thiazolidinediones increase the insulin sensitivity of adipose tissue, skeletal muscle, and the liver. Metformin, a biguanide, increases hepatic and peripheral insulin sensitivity, resulting in decreased hepatic glucose production.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Meglitinides]) | p. 217 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 23. Acarbose lowers blood glucose by a. slowing glucose absorption. b. enhancing insulin secretion. c. decreasing hepatic glucose production. d. increasing peripheral glucose uptake.

ANS: A

Acarbose is an -glucosidase inhibitor. Simply stated, it slows the breakdown of ingested fat so that postprandial hyperglycemia is reduced. Acarbose works within the GI tract and does not act by enhancing insulin secretion, decreasing hepatic glucose production, or decreasing peripheral glucose uptake.

DIF: Application REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Alpha-Glucosidase Inhibitors]) | p. 217 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 24. Which oral antidiabetic agent requires administration for 6 to 14 weeks to achieve maximal therapeutic

effect? a. Tolbutamide b. Exenatide c. Metformin d. Rosiglitazone e. Glimepiride ANS: D

Pioglitazone (Actos) and rosiglitazone (Avandia) can take up to 6 to 14 weeks to achieve maximal effect. Tolbutamide, metformin, and glimepiride work much more quickly than the thiazolidinediones.

Exenatide is not an oral antidiabetic because it is administered subcutaneously.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Thiazolidinediones]) | p. 217 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 25. The U.S. Food and Drug Administration (FDA) recommends checking serum alanine aminotransferase

(ALT) levels before starting therapy with a. biguanides b. thiazolidinediones c. -glucosidase inhibitors

and periodically thereafter.

d. nonsulfonylurea secretagogues ANS: B

Hepatotoxicity has rarely been reported with rosiglitazone and pioglitazone. These drugs should not be used in patients with underlying liver disease or with ALT levels greater than 2.5 times the upper limit of normal. The FDA recommends checking serum ALT levels before starting therapy with thiazolidinediones and periodically thereafter.

DIF: Comprehension REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Thiazolidinediones]) | p. 217 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 26. Exenatide (Byetta) is the first of a new class of drugs called a. incretin mimetics. b. oral hypoglycemic agents. c. euglycemic agents. d. thiazolidinediones.

ANS: A

Exenatide is indicated as an alternative to starting insulin in patients with type II diabetes who have not achieved adequate control with metformin, a sulfonylurea, or both. Liraglutide (Victoza) is the newest drug in this category. It is also available as a subcutaneous injection. It is indicated for adjunct therapy to diet and exercise in patients with type 2 diabetes. Exenatide, an incretin mimetic, has an amino acid sequence similar to human glucagon-like peptide-1 (GLP-1) and in the presence of glucose acts to stimulate insulin secretion.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Glucagon-Like Peptide-1 Receptor Agonists]) | p. 216 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 27. Which of the following statements is true of pramlintide (Symlin)? a. It is an oral dipeptidyl-peptidase-4 (DPP-4) inhibitor. b. Its use leads to decreased caloric intake and potential weight loss. c. It is approved for type I diabetes as an adjunct treatment in patients who use

mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy. d. Both A and B are true. e. Both B and C are true.

ANS: E

Pramlintide (Symlin) is responsible for modulation of gastric emptying, prevention of the postprandial rise in plasma glucagon, and satiety, which leads to decreased caloric intake and potential weight loss.

It is approved for type I diabetes as an adjunct treatment in patients who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy. Pramlintide is an amylinomimetic agent. Sitagliptin is an oral DPP-4 inhibitor.

DIF: Comprehension REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Pramlintide]) | p. 217 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology

28. Which of the following antihyperglycemic drugs is a bile-acid sequestrant used to lower low-density

lipoprotein (LDL) cholesterol? a. Pramlintide b. Colesevelam c. DPP-4s d. Glucagon ANS: B

The mechanism of action of colesevelam in treating type II diabetes is unclear. It has been approved by the FDA as an adjunct to diet and exercise for the treatment of type II diabetes. It can cause constipation, nausea, dyspepsia, and increase serum triglyceride levels. It can interfere with absorption of other oral drugs. Colesevelam (WelChol) is a bile-acid sequestrant that is used to lower LDL cholesterol.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Bile Acid Sequestrants]) | p. 217 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 29. The criterion for a diagnosis of diabetes mellitus includes a hemoglobin A1C value of a. 2.0 b. 3.5 c. 5.0 d. 6.5 e. 8.0

% or higher?

ANS: D

The criterion is (1) two consecutive fasting plasma glucose levels higher than 126 mg/dl, or (2) a hemoglobin A1C value of 6.5% or higher, or (3) a 2-hour plasma glucose level of 200 mg/dl or higher during an oral glucose tolerance test, or (4) a randomly measured plasma glucose level of 200 mg/dl or higher in a patient with the classic symptoms of hyperglycemia or hyperglycemic crisis. The American Diabetes Association Standards of Medical Care in Diabetes recommends a hemoglobin A1C level below 7% in order to reduce the incidence and progression of microvascular and macrovascular complications in patients with both type 1 and type 2 diabetes.

DIF: Recall REF: Diabetes Mellitus | p. 208 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

30. Type I diabetes results from an autoimmune destruction of a. thyroid tissue. b. pancreatic  cells. c. synovial fluid. d. parotid gland tissue. e. liver cells.

ANS: B

The type 1 autoimmune response may be triggered by an infection, a slow virus, environmental insults, or some as yet unknown factor. There are many different autoimmune disorders; however, type I diabetes is due to autoimmune destruction of  cells in the pancreas.

DIF: Comprehension REF: Diabetes Mellitus (Types of Diabetes [Type 1]) | p. 208 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

31. A “pooped out” pancreas results from a. ketoacidosis. b. an autoimmune reaction. c. a delay in insulin secretion and insulin resistance. d. a lack of secretion of insulin.

ANS: C

The pancreas works overtime secreting a large amount of insulin without achieving the desired results, and eventually cannot keep up with the need for insulin. A tired pancreas is associated with delayed secretion of insulin so that blood glucose values are elevated, and  cells in the pancreas that have a reduced or delayed response to glucose. Ketoacidosis, an autoimmune etiology, and lack of insulin secretion are all associated with type 1 diabetes.

DIF: Comprehension REF: Diabetes Mellitus (Types of Diabetes [Type 2] [Box 18.1: Possible Causes of Type 2 Diabetes]) | p. 210 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 32. Which is considered first-line therapy for a patient with type 2 diabetes? a. Diet and exercise b. Glucagon c. Antihyperglycemic Drugs d. Insulin ANS: A

Type 2 diabetes is treated first with diet and exercise, then with orally acting agents, and finally with insulin if the previous modalities fail. Orally acting agents and insulin are used if diet and exercise fails. Glucagon is an antagonist to insulin. It may be used for the emergency treatment of hypoglycemia; however, glucose is usually preferred.

DIF: Comprehension REF: Diabetes Mellitus (Types of Diabetes [Type 2]) | p. 209 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

33. Patients with uncontrolled or undiagnosed diabetes are more prone to periodontal disease. Patients

with well-controlled diabetes are no more prone to periodontal disease than the general public. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

The periodontal status of the patient with well-controlled diabetes has been somewhat more controversial than for the patient with uncontrolled or undiagnosed diabetes. Despite the fact that some investigators have reported a lack of correlation between diabetes and an increase in the rate of periodontal disease, many other studies have come to the opposite conclusion.

DIF: Application REF: Diabetes Mellitus (Dental Implications of Diabetes [Periodontal Disease]) | p. 209 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 34. For every percentage point drop in hemoglobin A1C, the risk of microvascular complications decreases

by a. b. c. d. e.

%.

10 20 30 40 50

ANS: D

Intensive therapy with multiple insulin formulations for patients with diabetes demonstrated similar results. The risk decreases by 40%. Early intervention also appears to contribute to a reduction in macrovascular complications.

DIF: Recall OBJ: 3

REF: Diabetes Mellitus (Goals of Therapy) | p. 211 TOP: NBDHE, 6.0. Pharmacology

35. Exenatide (Byetta) will lower hemoglobin A1C levels by a. 0.00 to 0.05 b. 0.05 to 1.00 c. 1.00 to 1.5 d. 1.5 to 2.0 e. 2.0 to 2.5

%.

ANS: C

Exenatide is indicated as an alternative to starting insulin in patients with type 2 diabetes in whom adequate control has not been achieved with metformin, a sulfonylurea, or both. Exenatide is an incretin mimetic that has an amino acid sequence similar to human glucagon-like-peptide-1 (GLP-1) and in the presence of glucose acts to stimulate secretion of insulin. This group of drugs lowers hemoglobin A1C levels by 1 to 1.5% and lowers weight by about 3 to 6 pounds.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Glucagon-Like Peptide-1 Receptor Agonists]) | p. 217 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Insulin is a pancreatic hormone that promotes insulin storage.

ANS: T

Insulin promotes fuel storage, whereas glucagon promotes fuel mobilization.

DIF: Recall REF: Pancreatic Hormones | p. 208 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. More people are diagnosed with type II diabetes in the United States than are diagnosed with type I

diabetes.

ANS: T

Over 34 million people in the United States have diabetes. The vast majority of these people, 90% to 95%, are diagnosed with type 2 diabetes. Both environmental and genetic factors are believed to contribute to the pathogenesis of type 2 diabetes. It is thought that the hyperglycemia leads to the many complications of diabetes.

DIF: Recall REF: Diabetes Mellitus | p. 208 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

3. Diabetes is the major cause of blindness in adults.

ANS: T

Because microvascular disease affects the blood supply to the retina, functioning of the retina is impaired in the person with diabetes.

DIF: Recall REF: Diabetes Mellitus (Systemic Complications of Diabetes [Retinopathy]) | p. 211 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. The hemoglobin A1C test more accurately measures the patient’s overall serum glucose control than the

fasting plasma glucose test.

ANS: T

Plasma glucose is a measure of the patient’s glucose control at the time that the blood is sampled. It does not reflect the patient’s overall glucose control. The hemoglobin A1C test more accurately measures the patient’s overall serum glucose control because it reflects the glucose control over a 2- to 3-month period.

DIF: Recall REF: Diabetes Mellitus (Evaluation of the Dental Patient With Diabetes) | p. 211 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 5. The hemoglobin A1C level should be more than 50% to reduce the incidence and progression of

microvascular complications in patients with diabetes.

ANS: F

The American Diabetes Association Standards of Medical Care in Diabetes recommends a hemoglobin A1C level below 7% in order to reduce the incidence and progression of microvascular and macrovascular complications in patient with both type 1 and type 2 diabetes.

DIF: Recall OBJ: 3

REF: Diabetes Mellitus (Goals of Therapy) | p. 211 TOP: NBDHE, 6.0. Pharmacology

6. Acarbose (Precose) slows the breakdown of ingested carbohydrates so that postprandial hyperglycemia

is reduced.

ANS: T

Acarbose (Precose) is an -glucosidase inhibitor. It slows the breakdown of ingested carbohydrates so that postprandial hyperglycemia is reduced.

DIF: Recall REF: Drugs Used to Manage Diabetes (Antihyperglycemic Drugs for Type 2 Diabetes [Alpha-Glucosidase Inhibitors]) | p. 217 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

Chapter 19: Drugs for the Treatment of Other Endocrine Disorders Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which of the following glands is also called the “master gland”? a. Thyroid gland b. Anterior pituitary gland c. Pituitary gland d. Gonads ANS: C

The pituitary gland secretes peptide hormones that regulate the thyroid, adrenal, and sex glands; the kidney and the uterus; and growth. In addition to their regulatory effect, the pituitary hormones have a trophic effect that is necessary for the maintenance of many systems. The pituitary gland (hypophysis) is a small endocrine organ located at the base of the brain. It has been called the “master gland” because of its regulatory effect on other endocrine glands and organs of the body.

DIF: Recall REF: Pituitary Hormones | p. 219 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. Hypopituitarism can produce a. goiter. b. acromegaly. c. diabetes insipidus. d. giantism.

ANS: C

Primary hypopituitarism can produce a loss of secondary sex characteristics, decreased metabolism, dwarfism, diabetes insipidus, hypothyroidism, Addison disease, loss of pigmentation, thinning and softening of the skin, decreased libido, and retarded dental development. Hypersecretion of pituitary hormones can produce sexual precocity, goiter, Cushing disease, acromegaly, and giantism.

DIF: Recall REF: Pituitary Hormones | p. 219 TOP: NBDHE, 6.0. Pharmacology 3. Leuprolide is used to treat a. hyperthyroidism. b. diabetes. c. fertility problems. d. hypothyroidism.

ANS: C

OBJ: 1

Leuprolide is a gonadotropin-releasing hormone (GnRH) analog. It stimulates the pituitary function and is used to treat infertility. GnRH agonists are used to treat prostate cancer and endometriosis.

Leuprolide does not effectively treat hyperthyroidism, diabetes, or hypothyroidism.

DIF: Comprehension REF: Pituitary Hormones (Anterior Pituitary) | p. 219 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. Which of the following is used in infertility cases to stimulate ovarian follicle development? a. Follicle-stimulating hormone (FSH) b. Luteinizing hormone (LH) c. Human chorionic gonadotropin (hCG) d. Human menopausal gonadotropin (hMG) ANS: D

hMG preparation is used in infertility cases to stimulate ovarian follicle development. When follicular maturation has occurred, the hMG is discontinued and hCG is given to induce ovulation. hMG contains FSH and LH and is commercially available as menotropin (Pergonal).

DIF: Comprehension REF: Pituitary Hormones (Anterior Pituitary) | p. 219 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 5. The posterior pituitary secretes a. prolactin. b. oxytocin. c. corticotrophin-releasing hormone. d. All of the above. e. None of the above.

ANS: B

Oxytocin and vasopressin (ADH) are synthesized in and secreted from the posterior pituitary. Prolactin is found in the anterior pituitary, and corticotrophin-releasing hormone is found in the hypothalamus.

DIF: Recall OBJ: 1

REF: Pituitary Hormones (Posterior Pituitary) | p. 221 TOP: NBDHE, 6.0. Pharmacology

6. Synthetic analogs of vasopressin are used to: (1) treat pituitary diabetes insipidus, (2) treat hemophilia

A and von Willebrand disease, (3) induce labor and postpartum lactation, (4) control postpartum hemorrhage. a. 1, 2, 3, 4 b. 1, 2, 3 c. 2, 3, 4 d. 1, 2 e. 3, 4 ANS: D

Synthetic analogs of vasopressin (desmopressin [DDAVP, Stimate]) and lypressin (Diapid) are used for chronic treatment of pituitary diabetes insipidus and to treat certain clotting disorders (hemophilia A and von Willebrand disease). These two analogs are available as nasal solutions and have the same action as vasopressin but are longer acting. Oxytocin, administered either by injection or intranasally, is used to induce labor, control postpartum hemorrhage, and induce postpartum lactation.

DIF: Application OBJ: 1

REF: Pituitary Hormones (Posterior Pituitary) | p. 221 TOP: NBDHE, 6.0. Pharmacology

7. Simple goiter is prevalent in some areas of the world because iodine is abundant in most foods. a. Both the statement and the reason are correct. b. The statement is correct, but the reason is not. c. The statement is not correct, but the reason is correct. d. Neither the statement nor the reason is correct.

ANS: B

Marine life is the only common food that is naturally rich in iodine. Simple goiter is quite prevalent in some areas of the world because iodine is not abundant in most foods. Use of iodized salt has decreased the incidence of simple goiter in many countries.

DIF: Comprehension REF: Thyroid Hormones (Iodine) | p. 221 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. Cretins exhibit all of the following dental abnormalities except which one? a. Malocclusion b. Large teeth c. Delayed tooth eruption d. Increased tendency to develop periodontal disease ANS: B

The teeth are usually poorly shaped and carious. The gingiva is either inflamed or pale and enlarged.

Hypothyroid pregnant women tend to produce offspring with large teeth. Cretins do exhibit dental disorders such as malocclusion, delayed tooth eruption, and increased tendency to develop periodontal disease.

DIF: Comprehension REF: Thyroid Hormones (Hypothyroidism) | p. 221 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Which of the following statements is characteristic of diffuse toxic goiter? a. It is also known as Plummer disease. b. It is characterized by a diffusely enlarged, highly vascular thyroid gland. c. It occurs primarily in older patients and usually arises from long-standing nontoxic

goiter. d. Both A and B are characteristics. e. Both B and C are characteristics.

ANS: B

Diffuse toxic goiter is characterized by a diffusely enlarged, highly vascular thyroid gland. It is common in young adults and is considered to be a disorder of the immune response. Diffuse toxic goiter is called Graves’ disease. Toxic nodular goiter is called Plummer disease. Toxic nodular goiter is characterized by nodules within the gland that spontaneously secrete excessive amounts of hormone while the rest of the glandular tissue is atrophied. It occurs primarily in older patients and usually arises from long-standing nontoxic goiter.

DIF: Comprehension

REF: Thyroid Hormones (Hyperthyroidism) | p. 221

OBJ: 2

TOP: NBDHE, 6.0. Pharmacology

10. Exophthalmos is a characteristic sign of a. cretinism. b. hyperthyroidism. c. acromegaly. d. dwarfism. e. hyperprolactinemia.

ANS: B

Exophthalmos is protrusion of the eyeballs and is characteristic of hyperthyroidism. Oral manifestations include accelerated tooth eruption, marked loss of alveolar process, diffuse demineralization of the jawbone, and rapidly progressing periodontal disease. Cretinism is a deficiency of thyroid hormone, acromegaly is an overabundance of growth hormone, and dwarfism is a deficiency in growth hormone. Neither these nor hyperprolactinemia causes exophthalmos.

DIF: Recall OBJ: 2

REF: Thyroid Hormones (Hyperthyroidism) | pp. 221-222 TOP: NBDHE, 6.0. Pharmacology

11. Which of the following is usually the drug of choice for treatment of hyperthyroidism in patients older

than 21 years? a. Propylthiouracil b. Methimazole c. Radioactive iodide (131I) d. Propranolol ANS: C 131

I is usually the drug of choice for patients over 21 years. It is taken internally and sequestered by the gland; localized destruction of thyroid tissue results. Both 131I and thyroidectomy usually result in hypothyroidism because a dose that produces an inadequate effect would require repeating the procedure. Antithyroid drugs, such as propylthiouracil and methimazole, are used in patients who cannot tolerate surgery or treatment with 131I. These drugs inhibit the iodinization of tyrosine moieties and the coupling of the iodotyrosines. Propranolol is often given concomitantly with antithyroid agents.

DIF: Recall REF: Thyroid Hormones (Hyperthyroidism [Radioactive Iodide and Surgery]) | p. 222 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 12. The major female sex hormone(s) is (are) (1) estrogen, (2) androgen, (3) progestin. a. 1, 2, 3 b. 1, 2 c. 2, 3 d. 1, 3 e. 1 only ANS: D

They are secreted primarily by the ovaries but also by the testes and placenta. They are largely responsible for producing the female sex characteristics, developing the reproductive system, and preparing the reproductive system for conception. The two major female sex hormones are the estrogens and progestins.

DIF: Recall REF: Female Sex Hormones | p. 222 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

13. Which female hormone promotes egg maturation? a. Follicle-stimulating hormone (FSH) b. Luteinizing hormone (LH) c. Estrogen d. Progesterone e. Chorionic gonadotropin ANS: A

In response to increased FSH, an ovarian egg matures, and the follicle in which it is contained grows in size and begins to produce and secrete estrogen. LH causes secretory cells of the follicle to develop into the corpus luteum. Estrogen prepares the reproductive system for conception. Progesterone promotes secretory changes in the endometrium and prepares the uterus for implantation of the fertilized ovum. Chorionic gonadotropin is released from trophoblasts after implantation.

DIF: Comprehension REF: Female Sex Hormones | p. 223 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 14. Which of the following anterior pituitary hormones are involved in the female menstrual cycle: (1)

thyroid-stimulating hormone (TSH), (2) adrenocorticotropic hormone (ACTH), (3) follicle-stimulating hormone (FSH), (4) luteinizing hormone (LH)? a. 1, 2, 3, 4 b. 1, 2 c. 1, 3 d. 2, 3 e. 3, 4 ANS: E

In response to increased FSH, an ovarian egg matures, and the follicle in which it is contained grows in size and begins to produce and secrete estrogen. On day 1 of an average 28-day cycle, when the menstrual flow begins, the secretions of FSH and LH begin to increase. This release is caused by a reduction in the blood levels of estrogen and progesterone, which normally inhibit their release.

DIF: Application REF: Female Sex Hormones | p. 223 TOP: NBDHE, 6.0. Pharmacology 15. What causes ovulation on day 14 of the menstrual cycle? a. An increase in the rate of secretion of FSH and LH b. A decrease in the rate of secretion of FSH and LH c. The release of large quantities of estrogen d. The release of large quantities of progesterone ANS: A

OBJ: 3

On approximately day 12, for reasons not entirely understood, the rate of secretion of FSH and LH increase markedly to cause a rapid swelling of the follicle that culminates in ovulation on day 14. After ovulation, LH causes the secretory cells of the follicle to develop into a corpus luteum that secretes large quantities of estrogen and progesterone. This action causes a feedback decrease in the secretion of both FSH and LH. DIF: Recall REF: Female Sex Hormones | p. 223 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

16. Estrogens are used to treat menstrual disturbances such as uterine bleeding. Estrogen is also used to

reduce the symptoms of menopause. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second statement is false. d. The first statement is false; the second statement is true.

ANS: A

In addition to their presence in oral contraceptives, estrogens are used to treat menstrual disturbances (dysmenorrhea, dysfunctional uterine bleeding), osteoporosis, atrophic vaginitis, nondevelopment of the ovaries, hirsutism, cancer, and symptoms of menopause. Estrogens are used to treat uterine bleeding and to reduce the symptoms of menopause.

DIF: Comprehension REF: Female Sex Hormones (Estrogens) | p. 223 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 17. The increase in gingival inflammation may occur even with a decrease in the amount of plaque. This

circumstance may be a result of increased levels of prostaglandin E (PGE), estradiol, and progesterone in the saliva. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second statement is false. d. The first statement is false; the second statement is true.

ANS: A

Changes in sex hormone levels during the life of the female are related to the development of gingivitis at puberty, during pregnancy, and after menopause. Conscientious plaque control helps to minimize these conditions. An increase in prostaglandin E (PGE), estradiol, or progesterone in saliva can lead to an increase in gingival inflammation.

DIF: Comprehension REF: Female Sex Hormones (Estrogens [Effect on Oral Tissues]) | p. 224 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 18. Increases in estrogen and progestin levels are associated with which oral lesion? a. Aphthous stomatitis b. Caries c. Gingivitis d. Increased tooth mobility e. Lichen planus

ANS: C

Changes in sex hormone levels during a woman’s life are related to the development of gingivitis at puberty (puberty gingivitis), during pregnancy (pregnancy gingivitis), and after menopause (chronic desquamative gingivitis). Increases in sex hormone levels are not associated with aphthous stomatitis, caries, increased tooth mobility, or lichen planus.

DIF: Application OBJ: 3

REF: Female Sex Hormones (Estrogens [Effect on Oral Tissues]) | p. 224 TOP: NBDHE, 6.0. Pharmacology

19. Which of the following statements is true of progesterone during the normal female sexual cycle? a. Progesterone secretion declines if implantation does not occur by the end of the

menstrual cycle. b. If implantation takes place, the developing trophoblast secretes chorionic

gonadotropin, which sustains the corpus luteum, thus maintaining progesterone and estrogen levels. c. Progesterone stimulates uterine contractility. d. Both A and B are true. e. Both B and C are true.

ANS: D

If implantation does not occur by the end of the menstrual cycle, progesterone secretion declines, and the onset of menstruation occurs. If implantation takes place, the developing trophoblast secretes chorionic gonadotropin, which sustains the corpus luteum, thus maintaining progesterone and estrogen levels and preventing menstruation. Other effects of progesterone include suppression of uterine contractility, proliferation of the acini of the mammary gland, and alteration of transplantation immunity to prevent immunologic rejection of the fetus.

DIF: Application OBJ: 3

REF: Female Sex Hormones (Progestins) | p. 224 TOP: NBDHE, 6.0. Pharmacology

20. Why do postmenopausal women use medroxyprogesterone (Provera) in conjunction with estrogens? a. It potentiates estrogen and postmenopausal women require a higher amount. b. It prevents an increase in the risk of uterine cancer that can occur when estrogen is

used alone. c. It facilitates the passage of estrogen across membrane surfaces. d. It helps to prevent osteoporosis.

ANS: B

Women who have had a hysterectomy do not need to take medroxyprogesterone with estrogens.

Medroxyprogesterone prevents the increase in the risk of uterine cancer that can occur with unopposed estrogen.

DIF: Comprehension REF: Female Sex Hormones (Progestins) | p. 224 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 21. All of the following are side effects associated with oral contraceptives except which one? a. Blood clot b. Weight gain c. Headache

d. Nausea e. Anorexia ANS: E

The most common side effects are nausea and vomiting. Tolerance develops with continued treatment, and these symptoms usually disappear. Other side effects include uterine bleeding, vaginal discharge, edema, thrombophlebitis, weight gain, and hypertension. Estrogen therapy does not cause anorexia.

DIF: Comprehension REF: Female Sex Hormones (Estrogens) | p. 223 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 22. Which of the following conditions is a contraindication for the use of oral contraceptives? a. Chronic obstructive pulmonary disease b. Type II diabetes c. Carcinoma of the breast d. Splenectomy ANS: C

Contraindications for the use of oral contraceptives include thromboembolic disorders, significant dysfunction of the liver, known or suspected carcinoma of the breast or other estrogen-dependent neoplasm, and undiagnosed genital bleeding. Carcinoma of the breast is a contraindication for the use of oral contraceptives. The remaining choices are not.

DIF: Comprehension REF: Female Sex Hormones (Hormonal Contraceptives) | p. 225 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 23. Some antibiotics are thought to reduce the effectiveness of hormonal contraceptives by a. preventing absorption across the membrane surface of the enteric plexus. b. suppressing intestinal flora. c. chelation to form insoluble byproducts. d. forcing progesterone levels to be maintained.

ANS: B

Consequently, plasma concentrations of the steroids are said to be abnormally low, and the steroid is cleared more rapidly from the body than under normal circumstances. These antibiotics are thought to do so indirectly by suppressing the intestinal flora and thus diminishing the availability of hydrolytic enzymes to regenerate the parent steroid molecule.

DIF: Recall OBJ: 3

REF: Female Sex Hormones (Hormonal Contraceptives) | p. 225 TOP: NBDHE, 6.0. Pharmacology

24. Which of the following agents is used for the treatment of cancer of the prostate? a. Methyltestosterone b. Clomiphene c. Finasteride d. Tamoxifen e. Mifepristone ANS: C

Finasteride is Proscar. It is an antiandrogen that inhibits the 5a-reductase in the androgen synthesis pathway. Methyltestosterone is an androgen and would promote an androgen-responsive prostate tumor. Clomiphene is an estrogen partial agonist and may be used for male infertility, tamoxifen is an estrogen antagonist—an androgen antagonist is needed. Mifepristone is RU-486, a progestin antagonist.

DIF: Recall REF: Male Sex Hormones (Androgens [Table 19.4: Examples of Male Hormones, Agonists, and Antagonists, and Female Hormone Antagonists]) | p. 225 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 25. Which of the following agents is categorized as a schedule III controlled substance? a. Medroxyprogesterone b. Tamoxifen c. RU-486 d. Nandrolone e. Danazol ANS: D

Nandrolone is an androgenic steroid. It is categorized as a schedule III controlled substance because of its illicit use and abuse potential by athletes and body builders. The other choices are all noncontrolled prescription drugs.

DIF: Application REF: Male Sex Hormones (Androgens) | p. 226 | Male Sex Hormones (Box 19.4: Androgenic Anabolic Steroids) | p. 226 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 26. Which of the following medications is indicated for the palliative treatment of advanced breast cancer

in postmenopausal women? a. Clomiphene b. Leuprolide c. Tamoxifen d. Danazol ANS: C

Tamoxifen is a competitive inhibitor of estradiol at the receptor. It is indicated in the palliative treatment of advanced breast cancer in postmenopausal women. Clomiphene has the ability to induce ovulation in some anovulatory women. Leuprolide is a GnRH analog used intramuscularly in the management of endometriosis and to treat infertility. Danazol possesses weak progestational and androgenic action.

DIF: Recall OBJ: 4

REF: Other Agents that Affect Sex Hormone Systems (Tamoxifen) | p. 227 TOP: NBDHE, 6.0. Pharmacology

27. Each of the following is a potential consequence of hypersecretion of pituitary hormones except one.

Which is the exception? a. Goiter b. Acromegaly c. Diabetes insipidus d. Cushing disease

e. Giantism ANS: C

Diabetes insipidus is a potential consequence of pituitary deficiency. Hypopituitarism can produce a loss of secondary sex characteristics, decreased metabolism, dwarfism, hypothyroidism, Addison disease, loss of pigmentation, thinning and softening of the skin, decreased libido, and retarded dental development. Hypersecretion can lead to sexual precocity, goiter, Cushing disease, acromegaly, and giantism.

DIF: Comprehension REF: Pituitary Hormones | p. 219 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 28. Which drug is administered to induce ovulation in a patient being treated for infertility? a. Human menopausal gonadotropin (hMG) b. Human chorionic gonadotropin (hCG) c. Luteinizing hormone (LH) d. Follicle-stimulating hormone (FSH) ANS: B

hCG is administered to induce ovulation when follicular maturation has occurred. Human menopausal gonadotropin (hMG) contains FSH and LH. It is commercially available as menotropin (Pergonal).

This preparation is used in infertility to stimulate the development of ovarian follicles.

DIF: Comprehension REF: Pituitary Hormones (Anterior Pituitary) | p. 219 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 29. The medical use of bromocriptine (Parlodel) is to a. stimulate pituitary function. b. inhibit pituitary function. c. stimulate thyroid function. d. inhibit thyroid function.

ANS: B

It is a dopamine agonist that suppresses prolactin levels. Bromocriptine is used to treat prolactinsecreting adenomas, acromegaly, and Parkinson disease. Bromocriptine inhibits pituitary function.

DIF: Comprehension REF: Pituitary Hormones (Anterior Pituitary [Bromocriptine]) | p. 221 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 30. Which pituitary hormone is used to treat diabetes insipidus? a. Menotropin (Pergonal) b. Oxytocin (Pitocin, Syntocinon) c. Vasopressin (Pitressin) d. Bromocriptine (Parlodel) ANS: C

Vasopressin is used for the treatment of transient diabetes insipidus. Menotropin is used to stimulate the development of ovarian follicles in the treatment of infertility. Oxytocin is used to induce labor, control postpartum hemorrhage, and induce postpartum lactation. Bromocriptine is an ergot derivative that inhibits pituitary function.

DIF: Comprehension REF: Pituitary Hormones (Posterior Pituitary) | p. 221 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 31. Thyroid hormones are synthesized from tyrosine and a. calcium. b. sodium. c. potassium. d. iodine. e. iron.

ANS: D

Thyroid hormones are synthesized from iodine and tyrosine and stored as a complex protein until thyroid-stimulating hormone (TSH) stimulates their release. The actions of thyroid hormones include those on growth and development, calorigenic effects, and metabolic effects. Calcitonin is a hormone secreted by the thyroid that regulates calcium metabolism. Sodium and potassium participate in transmission of nerve impulses. Iron is used to create hemoglobin in red blood cells.

DIF: Recall REF: Thyroid Hormones | p. 221 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

32. Which type of food contains high levels of iodine? a. Green vegetables b. Yellow vegetables c. Beef d. Citrus fruit e. Seafood ANS: E

Marine life is the only common food that is naturally rich in iodine. Without iodine, normal amounts of thyroid hormones cannot be made, thyroid-stimulating hormone (TSH) is secreted in excess, and the thyroid hypertrophies. Seafood is rich in iodine. Iodine is added to salt for use as a supplement for people in landlocked areas who do not get much iodine in their diet.

DIF: Recall OBJ: 2

REF: Thyroid Hormones (Iodine) | p. 221 TOP: NBDHE, 6.0. Pharmacology

33. Which drug is used to treat symptoms of menopause and postmenopausal osteoporosis? a. Clomiphene b. Leuprolide c. Tamoxifen d. Danazol e. Raloxifene ANS: E

Raloxifene (Evista) is a selective estrogen receptor modulator. Side effects include hot flashes, headache, dizziness, increased sweating, nausea, and vomiting. Clomiphene (Clomid, Serophene) has the ability to induce ovulation in some anovulatory women. Leuprolide (Lupron) is used to manage endometriosis and for the treatment of infertility. Tamoxifen (Nolvadex) is used for the treatment of early and advanced estrogen receptor-positive breast cancer in both premenopausal and postmenopausal women. Danazol (Danocrine) suppresses ovarian function and prevents the luteinizing hormone (LH) and follicle-stimulating hormone (FSH) midcycle surge.

DIF: Recall REF: Other Agents that Affect Sex Hormone Systems (Selective Estrogen Receptor Modulators) | p. 227 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 34. Which is the most common cause of hypothyroidism? a. Thyroid surgery b. Radiation therapy c. Hashimoto’s thyroiditis d. Medications to treat hyperthyroidism ANS: C

The most common cause of hypothyroidism is an autoimmune disease known as Hashimoto’s Thyroiditis. Other causes include medications to treat hyperthyroidism, thyroid surgery and radiation therapy. The more common symptoms of include difficulty sleeping, tiredness, fatigue, difficulty concentrating, dry skin and hair, depression, sensitivity to cold and muscle and joint pain.

DIF: Recall OBJ: 2

REF: Thyroid Hormones (Hypothyroidism) | p. 221 TOP: NBDHE, 6.0. Pharmacology

TRUE/FALSE 1. The anterior lobe of the pituitary gland secretes growth hormone.

ANS: T

It secretes growth hormone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroidstimulating hormone (TSH), adrenocorticotropic hormone (ACTH), and prolactin.

DIF: Recall OBJ: 1

REF: Pituitary Hormones (Anterior Pituitary) | p. 219 TOP: NBDHE, 6.0. Pharmacology

2. Synthetics analogs of vasopressin, a posterior pituitary hormone, may be used to treat diabetes.

ANS: T

They are used for chronic treatment of pituitary diabetes insipidus and to treat certain clotting disorders.

DIF: Recall OBJ: 1

REF: Pituitary Hormones (Posterior Pituitary) | p. 221 TOP: NBDHE, 6.0. Pharmacology

3. In most homeostatic systems the hormone released has a negative feedback effect on the secretion of

the hormone-stimulating substance.

ANS: T

Hormones help maintain homeostasis by regulating body functions and are controlled themselves by feedback systems.

DIF: Recall REF: Introduction | p. 219 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

4. No treatment should be initiated for any patient with a visible goiter, exophthalmos, or a history of

taking antithyroid drugs until approval is obtained from the patient’s physician.

ANS: T

Medical management of the condition is important before any elective surgery is performed. A surgical procedure or an acute oral infection could precipitate a crisis.

DIF: Recall OBJ: 2

REF: Thyroid Hormones (Hyperthyroidism) | p. 222 TOP: NBDHE, 6.0. Pharmacology

5. Estrogen therapy may promote endometrial carcinoma in postmenopausal women.

ANS: T

This risk may be canceled out by administration of a progestin for the last 10 days of the cycle.

DIF: Recall OBJ: 3

REF: Female Sex Hormones (Estrogens) | p. 223 TOP: NBDHE, 6.0. Pharmacology

6. Hormonal contraceptives have the potential to cause or aggravate gingival inflammation.

ANS: T

The hormones in contraceptives increase gingival fluid, stimulate gingivitis, and are associated with gingival inflammation similar but not as prominent as that seen in pregnancy.

DIF: Recall OBJ: 3

REF: Female Sex Hormones (Hormonal Contraceptives) | pp. 224-225 TOP: NBDHE, 6.0. Pharmacology

7. Hormones from the opposite sex are often used to manage prostate, breast, and uterine cancers.

ANS: T

The cancer is often stimulated by the patient’s own sex hormones. For example, prostate cancer is often stimulated by testosterone, so men with prostate cancer are given estrogens to inhibit the cancer’s growth.

DIF: Recall OBJ: 4

REF: Other Agents that Affect Sex Hormone Systems | p. 226 TOP: NBDHE, 6.0. Pharmacology

Chapter 20: Antineoplastic Drugs Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE

1. The phase of the cell cycle before mitosis and after the deoxyribonucleic acid (DNA) synthesis phase

is a. b. c. d. e.

G0.

M. G1.

S. G2.

ANS: E

G2 is preceded by S phase, in which DNA synthesis takes place, and is followed by M phase, in which mitosis occurs. G0 is the resting stage, in which the cells are “out of cycle” and not in the process of cell division. There are four stages in the reproductive cycle of a cell. G1 is the postmitotic or pre-DNA synthesis phase, S is the period of DNA synthesis, G 2 is the premitotic or post-DNA synthesis phase, and M, which is the period of mitosis.

DIF: Comprehension REF: Mechanisms of Action | p. 230 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Immune checkpoints are activated when

on the immune checkpoint recognize and bind to

partner proteins on the other cells. a. B-cells b. T-cells c. monocytes d. basophils e. neutrophils ANS: B

Immune checkpoints are activated by T-cells. When this happens an “off” message is sent to the Tcells and the tumor cells can then proliferate because the immune response has been shut down.

Immunotherapy drugs (protein kinase inhibitors) called immune checkpoint inhibitors block the checkpoint proteins from binding to the partner proteins and the “off” signal is never sent, allowing the T-cells to kill the cancer cells.

DIF: Application OBJ: 1

REF: Mechanisms of Action | pp. 230-231 TOP: NBDHE, 6.0. Pharmacology

3. Antimetabolites such as methotrexate attack the cells at the S phase of the cell cycle because they

interfere with purine and pyrimidine biosynthesis. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: A

They incorporate the drug into a compound or inhibit an enzyme from functioning and are more effective on rapidly proliferating neoplasms. Methotrexate, by inhibiting folic acid synthesis, decreases the ability of cells to make purines and pyrimidines, which are needed for DNA replication during the S (or synthetic) phase of the cell cycle.

DIF: Comprehension

REF: Classification | p. 233

OBJ: 1

TOP: NBDHE, 6.0. Pharmacology

4. An example of a cell-cycle nonspecific antineoplastic agent is a. bleomycin. b. cisplatin. c. methotrexate. d. vincristine.

ANS: B

Cisplatin, an inorganic platinum compound, has antitumor activity that is independent of which cell cycle phase a tumor cell is in. The actions of bleomycin, methotrexate, and vincristine are influenced by the phase of the cell cycle a tumor cell is in.

DIF: Recall REF: Classification | p. 233 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

5. Each of the following normal tissues is especially susceptible to the actions of antineoplastic drugs

except one. Which is the exception? a. Hair follicles b. Bone marrow c. Liver d. Gastrointestinal tract ANS: C

The most serious difficulty encountered in antineoplastic therapy stems from the lack of selectivity between tumor tissue and normal tissue. Some normal cells exhibit a faster reproduction cycle than do slowly growing tumor cells. In an effort to eradicate a malignancy, certain normal cells are also destroyed, resulting in adverse effects. Rapidly growing tissues are most susceptible to the antineoplastic agents. Liver cells grow much more slowly than those in hair follicles, bone marrow, and the gastrointestinal tract.

DIF: Application REF: Adverse Drug Effects | p. 233 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

6. Antineoplastic agents will have the greatest negative effect on which of the following tissues? a. Integumentary tissue b. Lungs, heart, and liver c. Gastrointestinal tract, bone marrow, and hair follicles d. Sensory tissue such as those for smell, sight, and hearing ANS: C

Gastrointestinal problems are common because the gastrointestinal tract tissue is rapidly turning over.

The sloughing of the gastrointestinal mucosa can produce many symptoms. Clinically, these disturbances are expressed as nausea, stomatitis, oral ulcerations, vomiting, and hemorrhagic diarrhea.

Because the cells of the gastrointestinal tract, bone marrow, and hair follicles are among the faster growing normal cells, the early side effects are associated with these tissues.

DIF: Recall REF: Adverse Drug Effects | p. 233 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

7. Which antineoplastic drug is a potent cardiotoxin? a. Methotrexate b. Vincristine c. Tamoxifen d. Mechlorethamine e. Doxorubicin ANS: E

Of the drugs listed, the antibiotic doxorubicin (Adriamycin) is a potent cardiotoxin. Vincristine is associated with peripheral neuropathy. Tamoxifen is associated with increased bone and tumor pain.

Mechlorethamine was used as nitrogen mustard during World War 1.

DIF: Comprehension REF: Adverse Drug Effects (Table 20.2: Selected Adverse Reactions of Some Antineoplastic Agents) | p. 234 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. Neurologic adverse effects are prevalent in all of the following antineoplastic agents except which

one? a. Asparaginase (Elspar) b. Methotrexate (Amethopterin) c. Vincristine (Oncovin) d. Procarbazine (Matulane) ANS: B

Methotrexate, a folic acid analog antimetabolite, does not cause any significant neurologic effects.

Methotrexate may be used after bone marrow transplantation to prevent or relieve graft versus host disease (GVHD). It is also used to treat other inflammatory conditions such as rheumatoid arthritis and ulcerative colitis. Asparaginase can produce seizures, vincristine peripheral neuropathy, and procarbazine psychic disturbances and monoamine oxidase inhibition.

DIF: Application REF: Adverse Drug Effects (Table 20.2: Selected Adverse Reactions of Some Antineoplastic Agents) | p. 234 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Which of the following are symptoms of adverse reactions caused by bone marrow suppression: (1)

susceptibility to infection, (2) bleeding, (3) high blood pressure, (4) fatigue? a. 1, 2, 3, 4 b. 1, 2, 4 c. 1, 3, 4 d. 1, 2 e. 3, 4 ANS: B

The degree of cytopenia that results depends on the drugs being used, the condition of the bone marrow at the time of administration, and other contributing factors. Symptoms of this adverse reaction may include susceptibility to infection, bleeding, and fatigue. The rise and fall in hematologic effects are related to location in the cycle of administering the drug. Inhibition of the bone marrow results in leukopenia or agranulocytosis, thrombocytopenia, and anemia.

DIF: Comprehension

REF: Adverse Drug Effects (Bone Marrow Suppression) | p. 233 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 10. The majority of cases of osteonecrosis have been reported in patients with cancer who are receiving a. b. c. d.

bisphosphonates. oral intravenous intramuscular subcutaneous

ANS: B

Approximately 94% of all cases of osteonecrosis have been reported in patients with cancer who are receiving intravenous bisphosphonates, particularly pamidronate and zoledronic acid, for multiple myeloma or metastatic carcinoma. Most cases of osteonecrosis are found with intravenous bisphosphonates. The incidence is much lower for patients who are taking oral bisphosphonates.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Osteonecrosis) | pp. 233-234 TOP: NBDHE, 6.0. Pharmacology

11. Medication-related osteonecrosis of the jaw (MRONJ) is an area of bone that has been exposed in the

mouth a. for more than 8 weeks to a bisphosphonate. b. following radiation therapy for head and neck cancer. c. as a consequence of necrotizing ulcerative periodontitis (NUP). d. under an ill-filling partial or complete denture.

ANS: A

The exact mechanism of action is unknown. It has been reported that bisphosphonates can produce microdamage because they alter bone deposition and the repair process. Prolonged use may suppress bone turnover to the point that microdamage persists and accumulates, which results in hypodynamic bone with decreased biomechanical competence. It is an area of bone in the mouth that has been exposed to bisphosphonates for more than 8 weeks.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Osteonecrosis) | p. 234 TOP: NBDHE, 6.0. Pharmacology

12. Which of the following is characteristic of Stage 2 medication-related osteonecrosis of the jaw

(MRONJ)? a. Exposed bone in the mouth b. Bone fracture c. A painful area of exposed bone d. No evidence of disease or soft tissue inflammation of the soft tissue around the bone ANS: C

During Stage 2 the patient presents with a painful area of exposed bone that is accompanied by soft tissue or bone inflammation or infection. During Stage 1 the patient presents with exposed bone that shows no evidence of disease or inflammation of the soft tissue around the bone. Stage 3 is associated with bone fracture. The patient also can present with an extensive amount of exposed bone and soft tissue inflammation and infection.

DIF: Comprehension REF: Adverse Drug Effects (Osteonecrosis) | p. 234 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. Medication-related osteonecrosis of the jaw (MRONJ) is most likely to occur after which of the

following dental procedures? a. Crown preparation b. Endodontic treatment c. Tooth extraction d. Prophylaxis ANS: C

There are several means to help minimize or prevent MRONJ. The dental hygienist should ask the patient if he or she is taking or receiving a bisphosphonate drug. Dental surgical procedures should be performed using minimal bone manipulation and supported with local and systemic antibiotic prophylaxis. Those with osteonecrosis of the jaw should have dead bone removed as necessary with minimal trauma to adjacent tissue. Most of the cases of osteonecrosis of the jaw occurred after tooth extractions and other dental procedures that traumatize the jaw.

DIF: Comprehension REF: Adverse Drug Effects (Osteonecrosis) | p. 234 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 14. Dental procedures should be performed for a patient taking bisphosphonates a. during bisphosphonate-free holidays. b. before starting bisphosphonate therapy or within 3 months of beginning therapy. c. only when the course bisphosphonate therapy has been completed. d. at any time deemed necessary.

ANS: B

Oral health examinations and any other dental procedure should be performed before starting bisphosphonate therapy or within 3 months of beginning therapy, if possible. Bisphosphonate-free holidays are not recommended before a dental procedure because these drugs stay in the bone for years. Bisphosphonate therapy is often stopped until the bone heals or the disease progresses to the point that bisphosphonate therapy is necessary.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Osteonecrosis) | p. 234 TOP: NBDHE, 6.0. Pharmacology

15. Nausea and vomiting caused by antineoplastic agent therapy can be managed by administration of a. procarbazine. b. codeine. c. omeprazole. d. prochlorperazine. e. cisplatin.

ANS: D

Prochlorperazine (Compazine) is a phenothiazine with marked antiemetic activity. Additional possibilities include: cannabinoids (dronabinol [Marinol] and nabilone [Cesamet]), metoclopramide (Reglan), and scopolamine. Procarbazine and cisplatin are antineoplastic agents. Omeprazole is a proton pump inhibitor, not an antiemetic, and codeine is a narcotic analgesic with nausea and vomiting as a significant side effect.

DIF: Recall OBJ: 3

REF: Adverse Drug Effects (Gastrointestinal Effects) | p. 235 TOP: NBDHE, 6.0. Pharmacology

16. Liver problems are most likely to occur with which of the following groups of antineoplastic agents? a. Alkylating agents b. Antimetabolites c. Antibiotics d. Hormones e. Immune modulators ANS: B

Liver problems occur principally with the antimetabolites (e.g., methotrexate [MTX]) but may occur with other agents as well. Liver problems are principally associated with one of the remaining choices of drugs.

DIF: Comprehension REF: Adverse Drug Effects (Hepatotoxicity) | p. 235 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 17.

effects are associated primarily with administration or vincristine (Oncovin) or vinblastine (Velban). a. Gastrointestinal b. Dermatologic c. Neurologic d. Immunosuppressant ANS: C

Vincristine and vinblastine are plant alkaloids. They act at mitotic spindle inhibitors causing arrest of the cell cycle at metaphase. Neurotoxic effects such as peripheral neuropathy, ileus, inappropriate antidiuretic hormone secretion, and convulsions have been associated primarily with vincristine or vinblastine administration.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Hepatotoxicity [Neurologic Effects]) | p. 235 TOP: NBDHE, 6.0. Pharmacology

18. Each of the following will have the action prolonged and toxicity increased by allopurinol, which is

used to prevent hyperuricemia, except one. Which is the exception? a. 5-Fluorouracil b. Azathioprine c. Cyclophosphamide d. Mercaptopurine ANS: A

The treatment of leukemia and lymphomas often results in rapid tumor destruction with a consequent high uric acid level. Allopurinol is a xanthine oxidase inhibitor used in the management of gout.

Allopurinol is administered to prevent hyperuricemia before the initiation of a regimen of antineoplastic agents that release purines and pyrimidines. Allopurinol decreases the metabolism and clearance of azathioprine and mercaptopurine, and increases the toxicity of cyclophosphamide. It does not enhance the toxicity of 5-fluorouracil.

DIF: Application OBJ: 2

REF: Adverse Drug Effects (Nephrotoxicity) | p. 235 TOP: NBDHE, 6.0. Pharmacology

19. What is the intraoral appearance of oral mucositis as a consequence of chemotherapy for cancer? a. Lacy white lines that represent Wickham striae b. Mouth sores on the soft tissue of the tongue and inside the mouth c. Single or small clusters of vesicles that quickly rupture, forming painful ulcers d. Chronic, multiple oral ulcerations and a history of oral and skin blisters ANS: B

Typical signs and symptoms include shiny, swollen tissue of the tongue and inside of the mouth, red, inflamed patches, sometimes white spots, and sticky mucous or blood in the mouth. The sores do not start right away. The patient usually begins to feel symptoms about 1 week after starting chemotherapy. The condition known as Wickham striae is associated with lichen planus. Single or small clusters of vesicles are associated with recurrent herpes simplex. Chronic multiple ulcerations are associated with pemphigus and mucous membrane pemphigoid.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Oral Effects) | p. 235 TOP: NBDHE, 6.0. Pharmacology

20. Which of the following is a treatment option to alleviate symptoms of mucositis? a. Injection of corticosteroids b. Oral rinse of 2% viscous lidocaine c. A 1-week course of oral antibiotics d. Use of a chlorhexidine rinse ANS: B

Lidocaine is often mixed with equal parts of diphenhydramine and either Maalox or Kaopectate.

More often than not, patients are treated with 2% viscous lidocaine. Treatment options include overthe-counter pain relievers such as ibuprofen and acetaminophen and opioid analgesics. Saline rinses and topical, alcohol-free mouth rinses with an anesthetic are used to treat the pain. Ice chips or cryotherapy have been used and appear to be effective in treating the pain associated with mucositis.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Oral Effects) | p. 236 TOP: NBDHE, 6.0. Pharmacology

21. One major concern of the dental health care worker is thrombocytopenia in patients undergoing

antineoplastic therapy because this can lead to an increased risk of infections. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: C

Thrombocytopenia is a concern for the dental health care worker, not because of an increased risk of infection (seen in agranulocytosis), but because of the increased risk of bleeding. After a cycle of drugs is completed, the effect on the bone marrow increases until the maximum effect is obtained. Dental treatment should be avoided during this time. The white blood cell count is often too low (agranulocytosis), and the chance of infection is great. The platelets may also be low (thrombocytopenia) and bleeding can occur.

DIF: Comprehension REF: Dental Implications | p. 236 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 22. The appointment should be scheduled

chemotherapy when providing oral care for patients on

antineoplastic agents. a. just before starting b. after the first few days of c. during the course of d. only after ANS: A

The procedures should be planned to coincide with the presence of the highest level of formed blood elements. That time would be either just before treatment or on the first few days of treatment.

Schedule the appointment for oral care for patients on antineoplastic agents just before the next chemotherapy.

DIF: Comprehension REF: Adverse Drug Effects (Oral Effects [Box 20.3: Oral Care for Patients on Antineoplastic Therapy]) | p.

235 | Dental Implications | p. 236 OBJ: 2|3 TOP: NBDHE, 6.0. Pharmacology 23. Each of the following neoplastic diseases has high sensitivity to chemotherapy except one. Which is

the exception? a. Acute lymphocytic leukemia b. Acute myelocytic leukemia c. Burkitt lymphoma d. Melanoma e. Hodgkin disease ANS: D

Liver cancer, pancreatic cancer, lung cancer, renal cancer, and malignant melanoma have little sensitivity to chemotherapy. Drugs are considered the primary choice for treatment of certain malignancies, including the leukemias, choriocarcinoma, multiple myeloma, and Burkitt lymphoma.

DIF: Comprehension REF: Use of Neoplastic Agents (Box 20.1: Sensitivity of Neoplastic Diseases to Chemotherapy) | p. 230 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 24. Which antineoplastic agent is used to manage breast cancer? a. Plant alkaloid b. Antibiotic c. Steroid

d. Estrogen e. Tamoxifen ANS: E

Tamoxifen is an antiestrogenic substance used to manage breast cancer. Plant alkaloids are mitotic inhibitors that act by arresting cells in metaphase. Antibiotics are cell-cycle nonspecific and are effective for solid tumors. Steroids are used to suppress lymphocytes in leukemias and lymphomas and in combination therapies. Estrogens are used palliatively for inoperable breast cancer.

DIF: Recall REF: Classification | p. 233 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

25. The most serious difficulty in antineoplastic therapy occurs due to a lack of selectivity between tumor

tissue and normal tissue. Some normal cells have a faster cell cycle than slowly growing tumor cells. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: A

In an effort to eradicate the malignancy, certain normal cells are destroyed which results in adverse effects. Rapidly growing cells are more susceptible to inhibition or destruction by antineoplastic agents.

DIF: Comprehension REF: Adverse Drug Effects | p. 233 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 26. Antineoplastic agents will affect bone marrow, leading to a. leukopenia and thrombocytopenia. b. leukocytosis and thrombocytopenia. c. leukopenia and polycythemia. d. leukocytosis and polycythemia.

ANS: A

Bone marrow is suppressed because it normally is turning over rapidly. Inhibition of bone marrow results in leukopenia or agranulocytosis, thrombocytopenia, and anemia. Leukocytosis is an increase in the number of white blood cells. Polycythemia is an increase in the concentration of hemoglobin in the blood.

DIF: Comprehension REF: Adverse Drug Effects (Bone Marrow Suppression) | p. 233 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 27. Bisphosphonates work to reduce osteoporosis by a. stimulating hemopoiesis. b. stimulating osteoblasts to produce new bone. c. binding to osteoclasts. d. remodeling cortical into cancellous bone. e. increasing blood flow within the osteon.

ANS: C

This allows bone production to continue, bone density to improve, and reduces the incidence of bone fractures. Bisphosphonates work by binding tightly to the bone directly beneath osteoclasts.

DIF: Comprehension REF: Adverse Drug Effects (Osteonecrosis) | p. 233 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 28. Which folic acid analog antimetabolite antineoplastic drug is also used to treat rheumatoid arthritis? a. Bleomycin (Blenoxane) b. Methotrexate (Amethopterin, MTX) c. Interferon alpha-n3 (Alferon N) d. Vincristine (Oncovin) e. Fluorouracil (5-FU) ANS: B

Antineoplastic drugs are used in lower doses to manage diseases associated with inflammatory or autoimmune conditions and transplantation. Diseases that are treated with these agents include rheumatoid arthritis, systemic lupus erythematosus, pemphigus vulgaris, and psoriasis. Bleomycin is an antibiotic. Interferon is an immune modulator. Vincristine is a plant alkaloid. Fluorouracil is a pyrimidine analog.

DIF: Application REF: Combinations | p. 236 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

TRUE/FALSE 1. Antineoplastic agents may be selected according to the type of cancer and how advanced it is.

ANS: T

There are many different drugs available to treat cancer. Therapy is dependent upon the type of cancer and how advanced the cancer is. Current antineoplastic therapy includes chemotherapy, hormone therapy, immunotherapy, radiation therapy, and targeted therapy.

DIF: Recall REF: Introduction | p. 229 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. The current philosophy for the use of antineoplastic agents involves treating the initial stages of the

disease very aggressively.

ANS: T

This approach not only promises more chance of controlling and curing the disease but also involves many severe side effects, including some that affect the oral cavity.

DIF: Recall OBJ: 1

REF: Use of Antineoplastic Agents | p. 229 TOP: NBDHE, 6.0. Pharmacology

3. Slowly growing cells are more susceptible to inhibition or destruction by antineoplastic agents.

ANS: F

Rapidly growing cells, such as neoplastic cells, are more susceptible to inhibition or destruction by antineoplastic agents.

DIF: Recall REF: Adverse Drug Effects | p. 233 TOP: NBDHE, 6.0. Pharmacology

OBJ: 2

4. Bisphosphonate-free holidays are not recommended before a dental procedure because these drugs stay

in the bone for years.

ANS: T

Bisphosphonate therapy is often stopped until the bone heals or the disease progresses to the point that bisphosphonate therapy is necessary.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Osteonecrosis) | p. 235 TOP: NBDHE, 6.0. Pharmacology

5. Antineoplastic agents stimulate the immune system.

ANS: F

Because antineoplastic agents have an immunosuppressant effect, enhanced susceptibility to infection or a second malignancy may occur after treatment.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Immunosuppression) | p. 235 TOP: NBDHE, 6.0. Pharmacology

6. The dental health care worker should not recommend any products containing alcohol to patients

taking antineoplastic agents because antineoplastic agents produce a disulfiram reaction.

ANS: F

The dental health care worker should not recommend any products containing alcohol because alcohol is drying to the oral mucosa.

DIF: Recall OBJ: 2

REF: Adverse Drug Effects (Oral Effects) | p. 235 TOP: NBDHE, 6.0. Pharmacology

Chapter 21: Emergency Drugs Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which of the following reasons is why the chance of an emergency occurring in the dental office

continues to increase? a. The average age of the dental patient has increased. b. Dental offices are administering more complicated regimens. c. Dental appointments are taking longer than they used to take. d. Dental patients are, on average, getting sicker. e. All of the above are reasons.

ANS: E

All statements are correct. An increasing number of older patients who are taking multiple drugs seek dental treatment each year. The demographics of our population, the use of fluorides, and management of periodontal disease have increased the age of the average dental patient. Dental offices are administering more complicated drug regimens; dental appointments are taking longer; and dental patients are on average getting sicker.

DIF: Comprehension REF: Introduction | p. 239 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Advanced Cardiac Life Support (ACLS) training is a. necessary for all staff. b. necessary if the office is in a rural setting. c. necessary if the office performs conscious sedation. d. not necessary for a dentist’s office. e. none of the above.

ANS: C

Each dental health care worker should be certified to perform CPR. The legal implications of lack of CPR training could be serious. ACLS training is required for personnel in dentist’s offices in which preoperative or conscious sedation is performed. It may be helpful in certain rural situations.

DIF: Comprehension REF: General Measures (Steps Indicated) | p. 239 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. Which of the following is a method of preventing an emergency in the dental office? a. Taking a complete patient history b. Training of personnel c. Posting the telephone numbers for the closest physician, emergency room, and

ambulance service d. Having a well-stocked and up-to-date emergency kit ANS: A

Taking a complete patient history can minimize and prevent emergencies. The other choices are measures to take in case of an emergency but not to prevent an emergency.

DIF: Recall REF: General Measures (Box 21.1: Methods of Minimizing Emergencies in the Dental Office) | p. 240 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. Which of the following represents the correct sequence for managing an emergency according to the

American Heart Association: A = Airway, B = Breathing, C = Chest compression? a. A, B, C b. A, C, B c. B, A, C d. B, C, A e. C, A, B ANS: E

(C) or chest compressions are now performed first, followed by assessing the airway (A), followed by breathing (B). The American Heart Association recommends that patients be assessed as follows: C-AB Chest compressions (C) are performed first, followed by assessment of the airway (A), and then breathing (B).

DIF: Comprehension REF: General Measures (Preparation for Treatment) | p. 239 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

5. Which of the following signs is the most common emergency in the dental office? a. Acute airway obstruction b. Syncope c. Hypoglycemia d. Diabetic coma ANS: B

The skin takes on an ashen-gray color, and diaphoresis occurs. The release of excessive epinephrine results in a pooling of the blood in the peripheral muscles ( effect, vasodilation), a decrease in total peripheral resistance, and a sudden fall in blood pressure. A reflex tachycardia follows, but soon, decompensation results in severe bradycardia. The emergency most often encountered in the dental office is simple syncope or transient unconsciousness. The release of excessive epinephrine results in a pooling of the blood in the peripheral muscles, a decrease in total peripheral resistance, and a sudden fall in blood pressure.

DIF: Recall REF: Categories of Emergencies (Lost or Altered Consciousness [Syncope]) | p. 240 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. Treatment for syncope is to place patients a. prone on their stomach with their head tilted to one side. b. supine with their head tilted to one side. c. seated with their head tilted back. d. seated with their head tilted forward.

ANS: B

This position causes blood to rush to the head, which has the effect of giving patients a transfusion of whole blood. Spirits of ammonia can be administered by inhalation. The old practice of putting the head between the legs should be avoided because venous return is cut off by the slumped position.

Treatment for syncope is to place patients supine with their head tilted to one side. They should be tilted back even further in the dental chair so that their head is below the level of the heart and turned to one side.

DIF: Application REF: Categories of Emergencies (Lost or Altered Consciousness [Syncope]) | p. 240 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 7. The most important component in the treatment of syncope is a. placing the patient in the Trendelenburg position. b. exhibiting confidence in action and voice. c. administering spirits of ammonia by inhalation.

d. placing the patient’s head between his or her legs.

ANS: B

If the hygienist shows control over the situation, the patient will be less anxious and apprehensive and less likely to repeat the syncopal attack. The most important thing is to exhibit confidence in action and voice.

DIF: Recall REF: Categories of Emergencies (Lost or Altered Consciousness [Syncope]) | p. 240 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. The most common cause of hypoglycemia is a. stress or anxiety. b. insufficient hydration with water. c. an excessive dose of insulin in a patient with diabetes. d. cardiac medication.

ANS: C

The medical history is important in this case, so the dental health care worker can determine the dose and type of insulin and food intake before the appointment. The most common cause of hypoglycemia is an excessive dose of insulin in a patient with diabetes. Patients often inject their daily dose of insulin but fail to eat before coming to the dental office.

DIF: Recall REF: Categories of Emergencies (Lost or Altered Consciousness [Hypoglycemia]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. The patient with hypoglycemia has a a. rapid; increased b. rapid; decreased c. slow; increased d. slow; decreased

pulse and

respiration.

ANS: B

They are very talkative (loquacious). Hunger, dizziness, weakness, and occasionally tremor of the hands can occur. Other signs of hypoglycemia include diaphoresis, nausea, and mental confusion. The patient can be given a sugary drink or oral glucose if the signs of hypoglycemia are recognized before they become severe. Patients with hypoglycemia have a rapid pulse and decreased respiration.

DIF: Comprehension REF: Categories of Emergencies (Lost or Altered Consciousness [Hypoglycemia]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 10. Which of the following treatment options is administered if a hypoglycemic patient lapses into

unconsciousness and does not have a swallowing reflex? a. Apple juice or an apple cut into small pieces b. Intravenous dextrose c. Cake icing injected by syringe into the back of the mouth d. A dollop of peanut butter on the tongue ANS: B

Intravenous dextrose is used to manage hypoglycemic episodes when a patient with diabetes is unconscious and cannot swallow. Hypoglycemia occurs most commonly when the patient’s insulin, exercise, and food intake are out of balance. If the patient lapses into unconsciousness and has no swallowing reflex, dextrose must be given intravenously.

DIF: Comprehension REF: Categories of Emergencies (Lost or Altered Consciousness [Hypoglycemia]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 11. Which of the following symptoms is associated with diabetic coma? a. Decreased pulse b. Increased appetite c. Acetone breath d. Cool, moist skin ANS: C

Treatment is undertaken only in a hospital setting and includes insulin after proper laboratory results are obtained. Symptoms of frequent urination, loss of appetite, nausea, vomiting, and thirst are noted.

Acetone breath; hypercapnia; warm, dry skin; rapid pulse; and a decrease in blood pressure can occur.

DIF: Comprehension REF: Categories of Emergencies (Lost or Altered Consciousness [Diabetic Coma]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 12. Diazepam may be administered for treatment of which of the following emergencies? a. Hyperglycemia b. Hypoglycemia c. Seizures d. Asthma e. Anaphylactic shock ANS: C

Generally, seizures are self-limiting, and treatment should include protecting the patient from selfharm, moving any sharp objects out of the patient’s reach, and turning the patient’s head to the side to prevent aspiration. Diazepam may be administered intravenously in some situations for the treatment of convulsions or seizures, but observation of the patient is often sufficient.

DIF: Application REF: Categories of Emergencies (Lost or Altered Consciousness [Seizures]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. Which of the following statements is true concerning treatment for a patient who is hyperventilating? a. Opioid analgesics or diazepam will resolve the situation. b. The treatment is calm reassurance. c. Steroids and aminophylline may be administered. d. Parenteral epinephrine is the drug of choice.

ANS: B

The treatment is calm reassurance. Position the patient upright, loosen tight clothing, and work with the patient to control his or her bleeding. Opioid analgesics or diazepam may be used to treat angina pectoris. Steroids, antibiotics, and aminophylline may be administered for aspiration. Parenteral epinephrine is the drug of choice for anaphylactic shock.

DIF: Comprehension REF: Categories of Emergencies (Respiratory Emergencies [Hyperventilation]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 14. For an asthma attack that is unresponsive to topical 2-agonist administration, what treatment recourse

does the dental office have available? a. Parenteral or oral aminophylline b. Parenteral corticosteroids c. Parenteral epinephrine d. Inhaled oxygen ANS: D

For an asthma attack that is unresponsive to topical 2-agonist, hospitalization should be considered for subsequent drug treatment. Oxygen can and should be administered. The other options should be considered at the hospital rather than the dentist’s office.

DIF: Comprehension REF: Categories of Emergencies (Respiratory Emergencies [Asthma]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 15. Anaphylactic shock is characterized by a a. weak, rapid b. weak, slow c. strong, rapid d. strong, slow

pulse.

ANS: A

The most common cause of anaphylactic shock is an injection of penicillin, although many other agents have caused anaphylactic reactions. The reaction usually begins within 5 to 30 minutes after ingestion or administration of the antigen. Usually, a weak, rapid pulse and a profound decrease in blood pressure occur with anaphylactic shock. Dyspnea and severe bronchial constriction occur.

DIF: Recall REF: Categories of Emergencies (Respiratory Emergencies [Anaphylactic Shock]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 16. Which of the following choices would be the correct sequence for administration of emergency drugs

for anaphylactic shock: (1) albuterol, (2) parenteral epinephrine, (3) intravenous corticosteroids? a. 1, 2, 3 b. 1, 3, 2 c. 2, 1, 3 d. 2, 3, 1 e. 3, 1, 2 ANS: C

Parenteral epinephrine may be given in the deltoid muscle or injected under the tongue. If bronchoconstriction is predominant, albuterol administered by inhalation or nebulization may suffice.

Intravenous corticosteroids, intramuscular diphenhydramine, and aminophylline may also be used after the life-threatening symptoms have been controlled. Parenteral epinephrine is the drug of choice and must be administered immediately in cases of severe anaphylactic shock.

DIF: Application REF: Categories of Emergencies (Respiratory Emergencies [Anaphylactic Shock]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 17. Each of the following actions is indicated for the management of acute airway obstruction EXCEPT

one. Which is the EXCEPTION? a. Placing the patient in a Trendelenburg position b. Clearing the pharynx and pulling the tongue forward c. Allowing the patient to sit upright d. Administering the Heimlich maneuver e. Performing cricothyrotomy ANS: C

Treatment begins by placing the patient in a Trendelenburg position on the right side and encouraging coughing. Clearing the pharynx and pulling the tongue forward before performing the Heimlich maneuver should be attempted next. Finally, the Heimlich maneuver should be performed and repeated if needed. A cricothyrotomy or tracheostomy is indicated if the object cannot be dislodged by other methods. Allowing the patient with acute airway obstruction to sit up is contraindicated. The other measures may be used to dislodge an acute airway obstruction.

DIF: Comprehension REF: Categories of Emergencies (Respiratory Emergencies [Acute Airway Obstruction]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 18. Which of the following drugs is the agent of choice for treating a drug-induced laryngospasm? a. Aminophylline b. Succinylcholine c. Parenteral epinephrine d. Diazepam ANS: B

Succinylcholine, a neuromuscular blocking agent, and positive-pressure oxygen are the agents of choice when drug-induced laryngospasm is present. The operator must have training and equipment to breathe artificially for the patient before succinylcholine is administered. The remaining choices do not represent the agent of choice for managing a drug-induced laryngospasm.

DIF: Recall REF: Categories of Emergencies (Respiratory Emergencies [Acute Airway Obstruction]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 19. Symptoms that differentiate myocardial infarction from angina pectoris include a. heaviness in the chest. b. pain that radiates across the chest to other parts of the body. c. pain unrelieved by nitroglycerin.

d. rapid pulse.

ANS: C

If the patient does not respond to sublingual nitroglycerin then a call should be placed for emergency services. Anginal pain is generally relieved by administration of nitroglycerin. If three doses of nitroglycerin do not relieve the pain, then myocardial infarction is strongly suspected.

DIF: Comprehension REF: Categories of Emergencies (Cardiovascular System Emergencies [Acute Myocardial Infarction]) | p. 242 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 20. An automated external defibrillator (AED), if administered within the first 5 minutes of cardiac arrest,

can save up to a. 10 b. 30 c. 50 d. 70 e. 90

% of persons experiencing cardiac arrest.

ANS: C

The first and most important treatment is to immediately recognize that cardiac arrest is occurring and activate the emergency response system. Early CPR with an emphasis on chest compressions should be initiated followed by rapid defibrillation, effective advanced life support, and integrated postcardiac arrest treatment. An AED can save up to 50% of persons experiencing cardiac arrest if it is administered within the first 5 minutes of cardiac arrest. The American Dental Association Council on Scientific Affairs recommended that dentists consider purchasing an AED for their dental offices if emergency medical services personnel with defibrillation skills and equipment are not available within a reasonable time period.

DIF: Recall REF: Categories of Emergencies (Cardiovascular System Emergencies [Cardiac Arrest]) | p. 242 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 21. Tepid baths and aspirin are indicated for a. myocardial infarction. b. thyroid storm. c. acute adrenocortical insufficiency. d. all of the above. e. none of the above.

ANS: B

One symptom of thyroid storm is hyperpyrexia. To reduce body temperature, aspirin and tepid baths are indicated. An aspirin tablet is indicated for myocardial infarction but not a tepid bath. Neither aspirin nor tepid bath is indicated for acute adrenocortical insufficiency.

DIF: Recall REF: Categories of Emergencies (Other Emergency Situations [Thyroid Storm]) | p. 244 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

22. Each of the following treatments is accepted for malignant hyperthermia EXCEPT one. Which is the

EXCEPTION? a. Succinylcholine b. Baths and aspirin c. Dantrolene d. Fluid replacement e. Sodium bicarbonate ANS: A

Succinylcholine is an agent that may precipitate malignant hyperthermia, not treat it. The other options are all accepted methods of managing malignant hyperthermia. Baths and aspirin are used to control rising temperature. Treatment with Dantrolene (Dantrium) can control acidosis and body temperature by reducing calcium released into muscles during the contractile response. Fluid replacement, steroids, and sodium bicarbonate may be used.

DIF: Comprehension REF: Categories of Emergencies (Other Emergency Situations [Malignant Hyperthermia]) | p. 244 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 23. The drug of choice for opioid overdose is a. intravenous diphenhydramine. b. prochlorperazine. c. naloxone. d. flumazenil.

ANS: C

Naloxone is an opioid-receptor antagonist that can specifically reverse the actions of the opioids. If the dental health practitioner suspects an opioid overdose then naloxone should be administered to the patient. Diphenhydramine is not a treatment of choice for opioid overdose, although it might reverse some of its actions. Prochlorperazine is not a treatment of choice for opioid overdose and may exacerbate the symptoms. Flumazenil is a benzodiazepine-receptor antagonist and would probably not influence the opioid overdose one way or the other.

DIF: Recall REF: Categories of Emergencies (Drug-Related Emergencies [Opioid Overdose]) | p. 244 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 24. Toxic reactions to epinephrine occur most often after the placement of a gingival retraction cord. The

treatment of choice is to administer an adrenergic-receptor antagonist. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Becoming panicky will cause the patient to release endogenous epinephrine, and the reaction will continue. The treatment of choice is to remove the retraction cord and reassure the patient. In a calm patient, the epinephrine will be metabolized, and the episode will not precipitate the release of endogenous epinephrine.

DIF: Comprehension REF: Categories of Emergencies (Drug-Related Emergencies [Epinephrine]) | p. 245 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 25. Which of the following is considered to be a Level 1: Critical Drug rather than a Level 2: Secondary

Drug? a. Atropine b. Glucagon c. Epinephrine d. Diazepam ANS: C

Epinephrine must be included in the dental office emergency kit for the treatment of cardiac arrest, anaphylaxis, or acute asthmatic attack. Atropine is used as a preoperative antisialagogue and to increase the cardiac rate when it has been slowed by vagal stimulation. Glucagon is used for the management of severe hypoglycemic reactions. Diazepam and midazolam are the drugs of choice for the treatment of most convulsions if a drug is needed.

DIF: Comprehension REF: Emergency Kit for the Dental Office (Drugs [Level 1 (Critical) Drugs]) | p. 245 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 26. Which of the following emergency drugs is used to manage hypoglycemia in a patient with diabetes? a. Diphenhydramine b. Nitroglycerin c. Albuterol d. Glucose ANS: D

The oral route of glucose is preferable if the patient can swallow. A small amount may be placed in the buccal pouch, where it can be slowly swallowed. Intravenous dextrose is used to manage hypoglycemia when a patient with diabetes is unconscious and cannot swallow. Diphenhydramine is an antihistamine that is used in the treatment of some allergic reactions. Nitroglycerin is used to manage an acute anginal attack. Albuterol is a short-acting 2-adrenergic agonist that produces bronchodilation.

DIF: Comprehension REF: Emergency Kit for the Dental Office (Drugs [Level 1 (Critical) Drugs]) | p. 246 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27. Which of the following drugs is administered to a patient who has suffered a myocardial infarction

(MI)? a. Morphine b. Procainamide c. Diphenhydramine d. Flumazenil ANS: A

Morphine and meperidine are opioid analgesics administered to a patient who has suffered an acute MI. These agents relieve pain and allay apprehension. Procainamide is used for an antiarrhythmic effect. Diphenhydramine is an antihistamine that is used in the treatment of some allergic reactions.

Flumazenil is a benzodiazepine antagonist used for reversing most of the effects of the benzodiazepines.

DIF: Recall OBJ: 3

REF: Emergency Kit for the Dental Office (Drugs [Level 2 Drugs]) | p. 247 TOP: NBDHE, 6.0. Pharmacology

28. Many dental offices will not have staff trained to use the more advanced (Level 2) emergency

equipment. Without training, attempts to use the more advanced equipment may be more harmful than using simple measures. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: A

With ACLS support training, a more advanced emergency kit can be prepared. Nasal and oral airways are used to maintain an unobstructed airway. Endotracheal tubes and a laryngoscope are required for intubation. Intravenous solutions, tubing, butterfly needles, and adhesive tape are used for intravenously administering drugs. A cricothyrotomy kit can be used for acute airway obstruction when other measures fail. Most dental office staff do not have more advanced training in the use of emergency equipment and their attempts may do more harm than good.

DIF: Comprehension REF: Emergency Kit for the Dental Office (Equipment) | p. 248 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 29. Each of the following is a telephone number that should be programmed into the speed dial function of

the office telephone system EXCEPT one. Which is the EXCEPTION? a. The closest physician b. The closest emergency room c. The closest ambulance service d. The closest pharmacy ANS: D

The closest pharmacy is not an emergency telephone number. The telephone numbers of the closest physician, emergency room, and ambulance service (often 911) should be posted and should be programmed into the speed dial function of the office phone system.

DIF: Application OBJ: 1

REF: General Measures (Steps Indicated) | p. 239 TOP: NBDHE, 6.0. Pharmacology

30. Which is administered for syncope? a. Nitroglycerin b. Spirits of ammonia c. Glucose d. Diphenhydramine

e. Glucagon ANS: B

Spirits of ammonia can be administered by inhalation. Nitroglycerin is used for the treatment of an acute anginal attack. Glucose is used for the treatment of hypoglycemia. Diphenhydramine is used for the treatment of an allergic reaction. Glucagon is used for the treatment of severe hypoglycemic reactions.

DIF: Comprehension REF: Categories of Emergencies (Lost or Altered Consciousness [Syncope]) | p. 240 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 31. Which should be administered first for a patient having an asthma attack? a. Aminophylline b. Corticosteroids c. 2-Agonist d. Epinephrine ANS: C

Patients who have an acute asthma attack usually have a history of previous attacks and carry their own medication. The patient’s own medication should be used first. Normally, this is a multidose inhaler containing a 2-agonist such as albuterol. If there is no response to an inhaler, hospitalization for administration of aminophylline and parenteral corticosteroids and epinephrine should be considered.

DIF: Comprehension REF: Categories of Emergencies (Respiratory Emergencies [Asthma]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 32. A patient with an acute airway obstruction who is conscious should first be placed in a semi-supine

position. If there is concern the patient may swallow the object, the patient should be placed in the Trendelenburg position on the right side. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: A

A finger sweep or suction should be used to clear the conscious patient’s throat and remove the object if possible. If the patient is conscious position them in a semi-supine position, clear their throat with a finger sweep or suction and remove the object if possible. Perform the Heimlich maneuver. If there is concern that they may swallow the object place the patient in the Trendelenburg position on the right side and encourage coughing.

DIF: Comprehension REF: Categories of Emergencies (Respiratory Emergencies [Acute Airway Obstruction]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 33. When a patient has a cardiac arrest permanent brain damage occurs within how many minutes? a. 2

b. c. d. e.

4 6 8 10

ANS: B

Cardiac arrest is fatal without immediate therapy. The window is 4 minutes. Early CPR with an emphasis on chest compressions should be initiated, followed by rapid defibrillation, effective advanced life support measures, and integrated post-cardiac arrest procedures.

DIF: Recall REF: Categories of Emergencies (Cardiovascular System Emergencies [Cardiac Arrest]) | p. 242 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 34. Each of the following is a type of kit for administration of naloxone EXCEPT one. Which is the

EXCEPTION? a. An intravenous (IV) dose form b. An intramuscular (IM) autoinjector with a retractable needle c. An inhaler d. A nasal spray e. A multistep nasal spray consisting of a prefilled Luer-Lok syringe with a nasal atomizer ANS: C

Naloxone is not available as an inhaler. The initial dose of the intravenous dose form is 0.4 mg (1 ml) intravenously. The autoinjector administers a 0.4 mg dose intramuscularly via a retractable needle. The nasal spray administers a dose concentration of 4 mg/0.1 ml. The multistep nasal spray administers a dose concentration of 2 mg/2 ml.

DIF: Comprehension REF: Emergency Kit for the Dental Office (Drugs [Level 1 (Critical)]) | p. 246 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 35. The initial dose of the intravenous form of naloxone is a. 0.2 mg. b. 0.4 mg. c. 0.6 mg. d. 0.8 mg.

ANS: B

The onset of action is approximately 2 minutes by the intravenous route. This dose should be repeated several times in case the dose of opioid was high. The initial dose is 0.4 mg intravenously, but it can also be administered subcutaneously or intramuscularly.

DIF: Recall REF: Emergency Kit for the Dental Office (Drugs [Level 1 (Critical) Drugs]) | p. 246 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE

1. Which of the following are considered to be Level 1 emergency devices? (Select all that apply.) a. Tourniquet b. Automated external defibrillator (AED) c. Laryngoscope d. Endotracheal tube ANS: A, B

Syringes/needles, tourniquets, a system to administer oxygen, and an automated external defibrillator (AED) are considered Level 1 emergency devices. A cricothyrotomy device, endotracheal tube, laryngoscope, and system to administer (IV) infusions are considered Level 2 emergency devices.

DIF: Recall REF: Emergency Kit for the Dental Office (Equipment [Box 21.3: Emergency Devices]) | p. 248 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Drugs are not necessary for the proper management of most emergencies.

ANS: T

The use of drug therapy is only ancillary to the primary measures of maintaining adequate circulation and respiration.

DIF: Recall OBJ: 1

REF: General Measures (Preparation for Treatment) | p. 239 TOP: NBDHE, 6.0. Pharmacology

2. Convulsions are generally self-limiting, and treatment should include protecting the patient from self-

harm.

ANS: T

Treatment should include protecting the patient from self-harm, moving any sharp objects out of the patient’s reach, and turning the patient’s head to the side to prevent aspiration.

DIF: Recall REF: Categories of Emergencies (Lost or Altered Consciousness [Seizures]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 3. The drug of choice for anaphylactic shock is sublingual or intramuscular injection of epinephrine.

ANS: T

Parenteral epinephrine is the drug of choice and must be administered immediately in cases of severe anaphylactic shock. It may be given in the deltoid muscle or injected under the tongue.

DIF: Recall REF: Categories of Emergencies (Respiratory Emergencies [Anaphylactic Shock]) | p. 241 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. Albuterol is a short-acting 2-adrenergic agonist that produces bronchoconstriction.

ANS: F

Albuterol produces bronchodilation. It is used in the management of an acute asthma attack or respiratory distress accompanying anaphylaxis.

DIF: Recall REF: Emergency Kit for the Dental Office (Drugs [Level 1 (Critical) Drugs]) | p. 245 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 5. Most dental offices are well equipped to treat cardiac arrhythmias.

ANS: F

The specific arrhythmia should be identified before an antiarrhythmic agent is selected. Most dental offices are not equipped to treat arrhythmias.

DIF: Recall OBJ: 3

REF: Emergency Kit for the Dental Office (Drugs [Other Drugs]) | p. 248 TOP: NBDHE, 6.0. Pharmacology

Chapter 22: Pregnancy and Breast Feeding Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which of the following statements is true regarding the dental management of the pregnant dental

patient? a. Avoid elective dental treatment except in the third trimester. b. Oral prophylaxis is best performed during the second trimester. c. The patient should be positioned in the Trendelenburg position during the last trimester. d. Both A and B are true. e. Both B and C are true.

ANS: B

Perform oral prophylaxis before pregnancy or during the second trimester; monitor for periodontal conditions. Because this is the time when the woman may feel nauseated at any time during the day or night, elective dental treatment should be avoided. Avoid elective dental treatment except in the second trimester. Position the patient in a recumbent position in the last trimester with the right hip elevated.

DIF: Comprehension REF: Pregnancy (Pregnancy Trimesters) | p. 249 | Box 22.1: Management of the Pregnant Dental Patient | p.

250 OBJ: 1 | 2 TOP: NBDHE, 6.0. Pharmacology 2. All of the following measures should be taken when prescribing drugs to a pregnant woman EXCEPT

one. Which is the EXCEPTION? a. No unnecessary drugs should be administered. b. An adequate health history should be taken at each appointment. c. Schedule morning appointments during the first trimester. d. Closely coordinate with the patient’s obstetrician.

ANS: C

Because of potential morning sickness during the first trimester, scheduling appointments in the afternoon is preferred during this period. The other options are all prudent measures to be followed with the pregnant dental patient.

DIF: Application OBJ: 1

REF: Pregnancy (Pregnancy Trimesters) | p. 249 TOP: NBDHE, 6.0. Pharmacology

3. Which of the following is a potential consequence of administering a drug to a pregnant woman? a. Teratogenicity to the fetus b. Spontaneous abortion c. Delayed and long-term physiologic and psychologic consequences d. Adverse reactions in the near-term fetus e. All of the above ANS: E

Spontaneous abortion could occur on early exposure to a toxic agent, followed by teratogenicity, especially if the drug is present while the organs are forming, followed by adverse reactions to the fully formed fetus. Finally, exposure to a drug in utero may lead to adverse consequences that do not emerge until later in life. All of the other answers cover the generally accepted concerns regarding drug administration to a pregnant woman.

DIF: Comprehension REF: General Principles (Two Main Concerns) | p. 249 | Pregnancy (Pregnancy Trimesters) | p. 249 OBJ: 1 | 2 TOP: NBDHE, 6.0. Pharmacology 4. The pregnant dental patient is most comfortable during which trimester? a. First trimester b. Second trimester c. Third trimester d. None of the above ANS: B

The second trimester is a good time to administer prophylaxis and any necessary dental treatment because the patient is beyond the morning sickness stages that might be experienced during the first trimester and is still comfortable reclining in the dentist’s chair for a moderate duration. The patient is most comfortable during the second trimester.

DIF: Comprehension REF: Pregnancy (Pregnancy Trimesters) | p. 249 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 5. Proving that a drug is teratogenic is difficult because a. drugs are uniformly teratogenic. b. the timing of the drug exposure is consistent for each drug. c. one drug can produce a variety of abnormalities, and different drugs can produce

the same abnormality. d. different animal species and humans are uniformly consistent in their responses to

drugs.

ANS: C

One drug can produce a variety of abnormalities, and different drugs can produce the same abnormality. Teratogenic drugs are not uniformly so. Timing of the drug exposure varies with each drug. Different animal species and humans vary among themselves in their responses to drugs.

DIF: Comprehension REF: Teratogenicity (Box 22.2: Reasons it is Difficult to Prove a Drug is Teratogenic) | p. 250 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 6. Each of the following is a subsection of the US Food and Drug Administration (FDA) pregnancy

categories EXCEPT one. Which is the EXCEPTION? a. Pregnancy b. Lactation c. Females and Males of Reproductive Potential d. Pregnancy categories A, B, C, D and X ANS: D

The US Food and Drug Administration (FDA) eliminated the pregnancy categories in 2015 with new information that is more meaningful for both practitioner and patient. The Pregnancy subsection provides information regarding dosing and potential risk to the developing fetus, pregnancy exposure registry, clinical considerations, and data on how women are affected when using medication. The Lactation subsection replaces the Nursing Mothers section and provides information regarding drugs that should not be used during breastfeeding, clinical considerations, risk benefits, timing of drug use, and nursing and the effects of all drugs on the nursing child. The Females and Males of Reproductive Potential subsection provides information regarding pregnancy testing, birth control, infertility, and the effects of medication on reproductive potential.

DIF: Application REF: Pregnancy (U.S. Food and Drug Administration Drug Use in Pregnancy and Lactation) | p. 245 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 7. Which dental anesthetic is contra-indicated for a pregnant woman? a. Lidocaine b. Mepivacaine c. Bupivacaine d. Epinephrine ANS: C

Bupivacaine has been shown to be teratogenic in rats and rabbits. Lidocaine, prilocaine, and etidocaine have been tested in animals without teratogenic effects. Mepivacaine has not been tested.

DIF: Comprehension REF: Dental Drugs (Local Anesthetic Agents) | p. 251 | Dental Drugs (Table 22.2: Dental Drug Use During Pregnancy) | pp. 252-253 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 8. Which of the following adverse effects is associated with smoking? a. Neonatal dependence b. Intrauterine growth retardation, sudden infant death syndrome c. Abnormal development patterns, neonatal withdrawal syndrome d. Increased spontaneous abortion, premature labor, abnormal development,

decreased school performance

ANS: B

Smoking is associated with intrauterine growth retardation and sudden infant death syndrome. Heroin is associated with neonatal dependence. Amphetamines are associated with abnormal development patterns and neonatal withdrawal syndrome. Cocaine is associated with increased spontaneous abortion, premature labor, abnormal development, and decreased school performance.

DIF: Recall REF: Pregnancy (Teratogenicity [Table 22.1: Selected Drugs With Adverse Effects on the Fetus]) | p. 250 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 9. Which of the following local anesthetics would be the best choice for dental application in the

pregnant patient? a. Prilocaine b. Lidocaine c. Bupivacaine d. Mepivacaine ANS: B

Lidocaine is the local anesthetic of first choice for the pregnant woman because of its low risk for both mother, developing fetus and child. Lidocaine is not associated with methemoglobinemia, as is prilocaine. Bupivacaine has been shown to be teratogenic in rats and rabbits. Mepivacaine has not been tested.

DIF: Comprehension REF: Dental Drugs (Local Anesthetic Agents) | p. 251 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 10. Which of the following agents can cause premature closure of the patent ductus arteriosus? a. Acetaminophen b. Clindamycin c. Triazolam d. Ibuprofen ANS: D

Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen can delay delivery, make it more difficult, and constrict the ductus arteriosus. NSAIDs also potentiate vasoconstriction if hypoxia exists.

The other choices do not produce this activity.

DIF: Comprehension REF: Dental Drugs (Analgesics [Nonsteroidal Antiinflammatory Drugs]) | p. 251 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 11. Which of the following is the NSAID of choice for a nursing mother? a. Ibuprofen b. Naproxen c. Diflunisal d. Ketoprofen ANS: A

Ibuprofen is the NSAID of choice for the nursing mother. All NSAIDs carry a warning to avoid use during pregnancy. For ibuprofen and naproxen, studies in animals have not shown adverse effects on the fetus. Diflunisal, but not naproxen, has been shown to be teratogenic in rabbits in large doses.

DIF: Recall REF: Dental Drugs (Analgesics [Nonsteroidal Antiinflammatory Drugs]) | p. 254 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 12. Which of the following opioids has been associated with teratogenicity? a. Morphine b. Codeine c. Lomotil d. Methadone ANS: B

Retrospective studies have associated the use of codeine during the first trimester with fetal abnormalities involving the respiratory, gastrointestinal, cardiac, and circulatory systems and with inguinal hernia and cleft lip and palate. These studies suggest that codeine or other opioids should not be used indiscriminately during the first trimester. The opioids, with the exception of codeine, have not been associated with teratogenicity. Whether the birth defects associated with codeine are related to its ubiquitous use or to some difference it possesses is not known.

DIF: Comprehension REF: Dental Drugs (Analgesics [Opioids]) | p. 254 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 13. Which of the following statements is true concerning the effect of opioids such as codeine on an infant

after administration to the mother? a. Opioids appear in breast milk when analgesic doses are administered. b. If the mother is addicted, the infant will experience withdrawal symptoms after birth. c. The infant should be observed for signs of euphoria. d. Both A and B are true. e. Both B and C are true.

ANS: D

Opioids appear in breast milk when analgesic doses are administered. The small doses appear to be insignificant. If the mother is addicted, the infant will experience withdrawal symptoms after birth.

The infant should be observed for signs of sedation and constipation.

DIF: Comprehension REF: Dental Drugs (Analgesics [Opioids]) | p. 254 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 14. Which of the following antiinfective agents is regarded as safe to use during pregnancy? a. Doxycycline b. Azithromycin c. Minocycline d. Amoxicillin ANS: D

Using amoxicillin for a dental infection that is not controlled by local measures would be acceptable during pregnancy. Amoxicillin appears in breast milk, and infants should be observed for signs of diarrhea, candidiasis, and allergic reactions. The consensus is that amoxicillin is safe to use during pregnancy.

DIF: Recall OBJ: 3

REF: Dental Drugs (Antiinfective Agents [Amoxicillin]) | p. 254 TOP: NBDHE, 6.0. Pharmacology

15. Each of the following agents has been demonstrated to produce skeletal abnormalities in the fetus

EXCEPT one. Which is the EXCEPTION? a. Doxycycline b. Erythromycin other than the estolate form c. Warfarin d. Aspirin ANS: B

Erythromycin, other than the estolate form, appears to be safe for use during pregnancy. The estolate form should not be used in pregnant women because it has been associated with reversible hepatic toxicity in the mother. Doxycycline can inhibit fetal bone growth, warfarin can cause chondrodysplasia and hypoplastic nasal bridge, and aspirin can cause birth defects involving the skeleton.

DIF: Application OBJ: 3

REF: Dental Drugs (Antiinfective Agents [Erythromycin]) | p. 254 TOP: NBDHE, 6.0. Pharmacology

16. Erythromycin is concentrated in breast milk. A nursing mother should be given erythromycin only if

the breast milk is expressed and discarded during treatment and 48 hours after the last dose. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second is false. d. The first statement is false; the second is true.

ANS: C

Erythromycin is available as a base, stearate, estolate, and ethyl succinate. All but the estolate form appear to be safe to use during pregnancy. Although erythromycin is concentrated in the breast milk, it has not been documented to produce problems.

DIF: Application OBJ: 3

REF: Dental Drugs (Antiinfective Agents [Erythromycin]) | p. 254 TOP: NBDHE, 6.0. Pharmacology

17. Which antiinfective agent is least teratogenic? a. Clarithromycin b. Acetaminophen c. Cephalexin d. Tetracycline ANS: C

First- and second-generation cephalosporins have not been associated with teratogenicity.

Clarithromycin should be avoided during the first trimester. It has been shown to be teratogenic in mice and monkeys. Acetaminophen has been shown to be teratogenic at overdose levels.

DIF: Application REF: Pregnancy (Teratogenicity) | p. 250 | Dental Drugs (Table 22.2: Dental Drug Use During Pregnancy) | pp. 252-253 | Dental Drugs (Antiinfective Agents [Cephalosporins]) | p. 254 | Dental Drugs (Antiinfective Agents [Tetracyclines]) | p. 254 OBJ: 2 | 3 TOP: NBDHE, 6.0. Pharmacology 18. Which of the following tetracyclines is (are) contraindicated in pregnancy: (1) tetracycline, (2)

minocycline, (3) doxycycline? a. 1, 2, 3 b. 1, 2 c. 2, 3 d. 1, 3 e. 1 only ANS: A

Tetracyclines cross the placenta and are deposited in fetal teeth and bones. Deciduous teeth may become stained, and fetal bone growth inhibited. All tetracyclines are contraindicated during pregnancy because of the potential for adversely affecting the fetus.

DIF: Comprehension REF: Dental Drugs (Table 22.2: Dental Drug Use During Pregnancy) | pp. 252-253 | Dental Drugs (Antiinfective Agents [Tetracyclines]) | p. 254 OBJ: 2 | 3 TOP: NBDHE, 6.0. Pharmacology 19. Which of the following antiinfective agents should be used for dental infections during pregnancy for

susceptible anaerobic infections not sensitive to penicillin? a. Amoxicillin b. Cephalosporins c. Clindamycin d. Metronidazole ANS: C

Clindamycin is also indicated for prophylaxis of endocarditis in penicillin-allergic patients. No adverse fetal problems have been reported. Clindamycin should be used for dental infections during pregnancy for susceptible anaerobic infections not sensitive to penicillin.

DIF: Recall OBJ: 3

REF: Dental Drugs (Antiinfective Agents [Clindamycin]) | p. 254 TOP: NBDHE, 6.0. Pharmacology

20. Metronidazole a. should only be used during the second trimester of pregnancy. b. is expressly contraindicated for the nursing mother. c. has been shown to produce birth defects in animals. d. Both A and B are correct. e. Both B and C are correct.

ANS: C

Metronidazole has been shown to produce birth defects in animals. It would be difficult to encounter a dental situation in which the risk to the fetus would not be greater than the benefit to the mother.

Metronidazole should be used carefully during the first trimester. The nursing mother should be given metronidazole only if breast milk is expressed and discarded during treatment and for 48 hours after the last dose.

DIF: Comprehension REF: Dental Drugs (Antiinfective Agents [Metronidazole]) | p. 254 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 21. Which of the following statements is true of the use of nystatin in either a pregnant woman or a

nursing infant? a. Nystatin may be used by either a pregnant woman or a nursing infant. b. Nystatin may be used by a pregnant woman, but not by a nursing infant. c. Nystatin may be used by a nursing infant, but not by a pregnant woman. d. Nystatin is not to be used by either a pregnant woman or a nursing infant.

ANS: A

Nystatin is not absorbed into the systemic circulation when taken orally or applied topically. Either the pregnant woman or the nursing infant also may use it to treat thrush. Nystatin is safe to use during pregnancy to treat oral Candida infections.

DIF: Comprehension REF: Dental Drugs (Antiinfective Agents [Nystatin]) | p. 254 TOP: NBDHE, 6.0. Pharmacology

OBJ: 3

22. Use of which of the following agents during pregnancy is associated with producing an abnormal

number of digits in the newborn? a. Alcohol b. Codeine c. Erythromycin d. Ketoconazole ANS: D

Ketoconazole has been shown to be teratogenic in rats, causing syndactyly and oligodactyly, an abnormal number of digits. Alcohol, codeine, and erythromycin are not commonly known to produce an abnormal number of digits in the newborn.

DIF: Comprehension REF: Dental Drugs (Antiinfective Agents [Ketoconazole]) | p. 255 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 23. Benzodiazepines are indicated for the treatment of during pregnancy. a. anxiety during oral surgery procedures b. discomfort during scaling and root planning procedures c. status epilepticus d. Both A and B e. Both B and C ANS: C

No dental use has been established. First-trimester use of benzodiazepines has been reported to increase the risk of congenital malformations. Cleft palate and lip and neural tube defects have been seen. Benzodiazepines are only indicated for the treatment of status epilepticus during pregnancy.

DIF: Application OBJ: 3

REF: Dental Drugs (Antianxiety Agents [Benzodiazepines]) | p. 255 TOP: NBDHE, 6.0. Pharmacology

24. Use of which of the following agents during pregnancy is associated with “floppy infant syndrome”? a. Naproxen b. Diazepam c. Nystatin d. Warfarin ANS: B

Chronic ingestion of benzodiazepines such as diazepam during pregnancy has produced physical dependence and “floppy infant syndrome.” Naproxen, nystatin, and warfarin do not cause “floppy infant syndrome.”

DIF: Comprehension REF: Dental Drugs (Antianxiety Agents [Benzodiazepines]) | p. 255 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 25. Which of the following statements is true concerning fetal alcohol syndrome (FAS)? a. FAS involves growth retardation, central nervous system (CNS) abnormalities, and

flat maxillary area or a thin lip. b. Infants born to mothers who drank throughout pregnancy show more tremors,

hypertonia, restlessness, crying, and abnormal reflexes compared with control groups after birth. c. The safe alcohol threshold for the pregnant woman is 2 ounces of alcohol or 24 ounces of beer a day. d. Both A and B are true. e. Both B and C are true.

ANS: D

FAS involves growth retardation, CNS abnormalities, and flat maxillary area or a thin lip. Infants born to mothers who drank throughout pregnancy show more tremors, hypertonia, restlessness, crying, and abnormal reflexes compared with control groups after birth. Pregnant dental patients should be encouraged to abstain from the ingestion of alcohol. No safe threshold level is known for the pregnant woman.

DIF: Recall OBJ: 3

REF: Dental Drugs (Antianxiety Agents [Alcohol]) | p. 256 TOP: NBDHE, 6.0. Pharmacology

26. Small doses of epinephrine in dental local anesthetic are similar to those produced endogenously.

Large doses could have adverse effects on the fetus. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second is false. d. The first statement is false; the second is true.

ANS: A

Local anesthetics without vasoconstrictor are preferred if procedures are short. Adverse effects include anoxia from vasoconstriction.

DIF: Comprehension REF: Dental Drugs (Epinephrine) | p. 251 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 27. Which is the best choice of analgesic for a pregnant patient? a. Acetylsalicylic acid (aspirin, ASA) b. Ibuprofen (Motrin) c. Naproxen (Naprosyn) d. Acetaminophen (Tylenol) ANS: D

In large doses, acetaminophen may be associated with renal changes in the fetus similar to those that occur in adults. Although no controlled studies in humans have been done, acetaminophen is generally considered to be safe during pregnancy.

DIF: Application OBJ: 3

REF: Dental Drugs (Analgesics [Acetaminophen]) | p. 254 TOP: NBDHE, 6.0. Pharmacology

28. Which operating personnel who are exposed to trace amounts of nitrous oxide have significantly

higher incidence of spontaneous abortion and birth defects in their children? a. Both women and men. b. Women but not men. c. Men but not women. d. Pregnant women only.

ANS: A

Methods for reducing the environmental exposure, especially long term, should be explored and implemented. Operating personnel, both male and female, who are exposed to trace amounts of nitrous oxide (N2O) have a significantly higher incidence of spontaneous abortion and birth defects in their children.

DIF: Recall REF: Dental Drugs (Antianxiety Agents [Nitrous Oxide-Oxygen Mixture]) | p. 255 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. In managing the pregnant patient, avoiding elective dental treatment is best until the third trimester.

ANS: F

The second trimester is the preferred time for dental treatment.

DIF: Recall OBJ: 2

REF: Pregnancy (Pregnancy Trimesters) | p. 249 TOP: NBDHE, 6.0. Pharmacology

2. Although opioids appear in breast milk when analgesic doses are administered, the small amounts

appear have an insignificant effect on the nursing infant.

ANS: T

Although large doses used by opioid addicts can cause adverse effects on the nursing infant, small analgesic doses appear to be safe.

DIF: Recall OBJ: 3

REF: Dental Drugs (Analgesics [Opioids]) | p. 254 TOP: NBDHE, 6.0. Pharmacology

3. Aspirin is generally considered to be the best analgesic to administer during pregnancy.

ANS: F

Aspirin can cause a variety of birth defects involving many organs. Acetaminophen is generally considered safe in pregnancy.

DIF: Recall OBJ: 3

REF: Dental Drugs (Analgesics [Aspirin]) | p. 251 TOP: NBDHE, 6.0. Pharmacology

4. All NSAIDs carry a warning to avoid use during pregnancy.

ANS: T

Studies in animals have not shown adverse effects on the fetus for ibuprofen and naproxen. Diflunisal (category C), but not naproxen (category B), has been shown to be teratogenic in rabbits in large doses.

DIF: Recall REF: Dental Drugs (Analgesics [Nonsteroidal Antiinflammatory Drugs]) | p. 254 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 5. The wives of dental personnel who are exposed to trace amounts of nitrous oxide in the workplace

have a higher incidence of spontaneous abortion.

ANS: T

Continued exposure to small amounts of nitrous oxide by a man or woman can adversely affect the progress of a subsequent pregnancy.

DIF: Recall REF: Dental Drugs (Antianxiety Agents [Nitrous Oxide-Oxygen Mixture]) | p. 255 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

Chapter 23: Substance Use Disorders Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. The potential for abuse of a drug is greatly increased by all of the following factors except which one? a. Very potent b. Long duration of action c. Inexpensive d. Easy to distribute ANS: B

The abuse potential of a drug is increased if it has a quick onset of action. The duration of action of the drug is less important, and a longer duration often reduces the opportunity for a subsequent “rush” and the cycle of repetitive use. Potency, cost, and ease of access are all incentives to maintain a drug habit.

DIF: Comprehension REF: Introduction | p. 258 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Agents capable of changing behavior or inducing a psychosis-like reaction are termed a. psychedelic. b. hallucinogenic. c. psychoactive. d. psychotomimetic.

ANS: C

The statement is the definition of psychoactive, which includes drugs with therapeutic value and those without therapeutic value. Psychedelic drugs are the subset of psychoactive drugs that have no therapeutic value. Hallucinogenic drugs may produce hallucinations and psychotic-like behavior and are categorized with psychedelic drugs. Psychotomimetic drugs produce effects that mimic psychoses; they exclude several psychoactive drugs that do not mimic psychoses.

DIF: Recall REF: Introduction | p. 258 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. The recurrent use of alcohol and/or drugs causing clinically and functionally significant impairment is

called a. enabling. b. psychologic dependence. c. substance use disorders. d. tolerance. e. abstinence syndrome.

ANS: C

According to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria. Substance Use Disorders are defined as mild, moderate, or severe that is determined by the number of criteria that the person demonstrates. Enabling is the behavior of family or friends that allow the drug-dependent person to continue his or her habit. The definition applies to more than psychologic dependence. Tolerance often occurs before or during but is not equivalent to drug dependence. Abstinence syndrome or withdrawal is a set of physical and psychologic symptoms that occurs when a drug-dependent person stops taking a drug. One symptom might be the compulsion to take the drug.

DIF: Recall OBJ: 1

REF: General Considerations (Definitions) | pp. 258-259 TOP: NBDHE, 6.0. Pharmacology

4. Enabling is an inappropriate behavior that requires family therapy because it involves the actions that

family or friends take to supply the addict with the drug. a. Both the statement and the reason are correct and related. b. Both the statement and the reason are correct but not related.

c. The statement is correct, but the reason is not. d. The statement is not correct, but the reason is correct. e. Neither the statement nor the reason is correct.

ANS: C

Enabling is an inappropriate coping mechanism that requires family therapy. Enabling is the behavior of family or friends who associate with the addict that results in continued substance abuse. It may have nothing to do with providing the addict with the drug. Thus, because this dysfunctional behavior is counterproductive, the first statement is true. However, enabling is much more subtle than actually supplying the drug.

DIF: Application OBJ: 1

REF: General Considerations (Definitions) | p. 259 TOP: NBDHE, 6.0. Pharmacology

5. All of the following statements are descriptive of psychologic dependence except which one? a. It may vary from mild desire to compulsive obsession. b. It is not as strong as physical dependence. c. It often involves drug-seeking behavior. d. It is a state in which the person feels unable to maintain optimal performance

without the drug.

ANS: B

Even though some highly abused drugs have only psychologic dependence, the “need” to use these drugs can be as strong or stronger than drugs with a physical dependence. All other statements are characteristic of psychologic dependence.

DIF: Comprehension REF: General Considerations (Psychological Dependence) | p. 259 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 6. Physical dependence a. is a state of mind in which a person believes that he or she is unable to maintain

optimal performance without having taken a drug. b. is established by withdrawal syndrome. c. refers to the altered physiologic state that results from constantly increasing drug

concentrations. d. Both A and B are correct. e. Both B and C are correct.

ANS: E

Physical dependence refers to the altered physiologic state that results from constantly increasing drug concentrations. It is established by withdrawal syndrome, a combination of many drug-specific symptoms that occur on abrupt discontinuation of drug administration. Psychologic dependence is a state of mind in which a person believes that he or she is unable to maintain optimal performance without having taken a drug.

DIF: Comprehension REF: General Considerations (Physical Dependence) | p. 259 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

7. Tolerance is characterized by the need to

providing the same dose that produces a(n) a. increase; increasing b. increase; diminishing c. decrease; increasing d. decrease; diminishing

the dose continually to achieve a desired effect or effect.

ANS: B

In terminal patients, this tolerance requires ever-increasing doses of opioids even if the pain remains constant. Tolerance is characterized by the need to increase the dose continually to achieve a desired effect or providing the same dose that produces a diminishing effect.

DIF: Comprehension REF: General Considerations (Tolerance) | p. 259 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 8. Which of the following statements is true regarding addiction and habituation? a. When comparing drugs of the same group, the time required to produce physical

dependence is longest with a rapidly metabolized drug and shortest with a slowly metabolized drug. b. Cross-tolerance may be either partial or complete and is determined more by the pharmacologic effect of the drug than by its chemical structure. c. The longer the half-life of the drug is, the quicker the withdrawal will be. d. A barbiturate can be substituted for an opioid, and vice versa.

ANS: B

Cross-tolerance may be either partial or complete and is determined more by the pharmacologic effect of the drug than by its chemical structure. When comparing drugs of the same group, the time required to produce physical dependence is shortest with a rapidly metabolized drug and longest with a slowly metabolized drug. The shorter the half-life is, the quicker the withdrawal will be. If a person is addicted to heroin, an opioid, then other opioids, such as morphine, can prevent withdrawal. However, a barbiturate cannot be substituted for an opioid, and vice versa.

DIF: Comprehension REF: General Considerations (Addiction and Habituation) | p. 259 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 9. Approximately a. 20 b. 40 c. 60 d. 80

% of incarcerated individuals are there because of drug abuse problems.

ANS: D

Approximately 80% of incarcerated (jailed) individuals are there because of substance use disorder problems. Approximately 80% are incarcerated because of problems with substance use disorder. All other choices are incorrect.

DIF: Recall OBJ: 1

REF: General Considerations (Addiction and Habituation) | p. 259 TOP: NBDHE, 6.0. Pharmacology

10. Abuse of is the number one public health problem in the United States. a. opioids b. stimulants c. alcohol d. hallucinogens ANS: C

Abuse of alcohol, called alcohol use disorder, is the number one public health problem in the United States. Because it is legal, its availability makes it the most often abused drug. All other choices are incorrect.

DIF: Recall OBJ: 2

REF: Central Nervous System Depressants (Ethyl Alcohol) | p. 260 TOP: NBDHE, 6.0. Pharmacology

11. How many Americans who drink are heavy alcohol users? a. 600,000 thousand b. 6 million c. 16 million d. 26 million ANS: C

In 2010, alcohol misuse costs the United States 249 billion dollars. Three quarters of the total cost of alcohol misuse are related to binge drinking. Data from the National Survey on Drug Use and Health 2016 showed that 50.7% of all Americans age 12 and older reported drinking alcohol. Most drink in moderation, however, over 16 million Americans who drink alcohol are heavy alcohol users.

DIF: Recall OBJ: 2

REF: Central Nervous System Depressants (Ethyl Alcohol) | p. 260 TOP: NBDHE, 6.0. Pharmacology

12. Which of the following choices is not a symptom of ethyl alcohol intoxication? a. Constricted pupils b. Impairment of judgment c. Ataxia d. Emotional lability ANS: A

Moderate acute intoxication with ethyl alcohol produces dilated pupils, not constricted pupils. The other choices are all characteristic of ethyl alcohol intoxication.

DIF: Comprehension REF: Central Nervous System Depressants (Ethyl Alcohol [Acute Intoxication]) | p. 260 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. At which stage of ethyl alcohol withdrawal are hallucinations most prevalent? a. Stage 1 b. Stage 2 c. Stage 3 d. Ethyl alcohol withdrawal is not associated with hallucinations ANS: B

Stage 2 withdrawal includes hallucinations, paranoid behavior, and amnesia. Although overlap in symptoms can be considerable, hallucinations generally occur after stage 1 and before stage 3.

DIF: Comprehension REF: Central Nervous System Depressants (Ethyl Alcohol [Withdrawal]) | p. 260 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 14. Chronic alcohol use increases the risk of cancer of the mouth, pharynx, larynx, esophagus, and liver,

which may occur with tobacco use in a(n) a. additive b. synergistic c. negative d. canceling

effect.

ANS: B

The liver can be affected with alcoholic hepatitis and amnestic syndrome (Wernicke-Korsakoff) syndrome, and peripheral neuropathy can occur. Chronic alcohol use increases the risk of cancer of the mouth, pharynx, larynx, esophagus, and liver, which may occur with tobacco use to make the risk higher than with alcohol alone.

DIF: Application REF: Central Nervous System Depressants (Ethyl Alcohol [Long-Term Effects]) | pp. 260-261 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 15. Which of the following statements is true of alcohol use disorder? a. A genetic link for alcohol use disorder exists. b. Inpatient detoxification is required for most alcoholics. c. Penicillin is known to produce a disulfiram-like reaction. d. A patient will vomit if he or she takes naltrexone while consuming alcohol.

ANS: A

Genetic testing may someday be able to identify at-risk children and target this population for intense educational and social intervention for prevention. A genetic link for alcohol use disorder has been found; children of alcoholics are at much greater risk for becoming alcoholics. Inpatient treatment does not give the alcoholic any experience in recovery in the “real world.” Disulfiram (Antabuse) rather than penicillin is associated with a deterrent reaction. Certain other drugs that produce the disulfiramlike reaction (e.g., metronidazole) may cause a minor version of these symptoms with alcohol consumption.

DIF: Recall REF: Central Nervous System Depressants (Ethyl Alcohol [Alcohol Use Disorder]) | p. 261 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 16. Disulfiram is an agent used in the treatment of a. ethyl alcohol withdrawal. b. opioid withdrawal. c. barbiturate overdose. d. alcohol use disorder.

ANS: D

Disulfiram (Antabuse) hinders alcohol metabolism and leads to a rise in acetaldehyde in drinkers. This property acts as a deterrent to drinking and as an incentive to stay sober. Disulfiram is not effective in any of the other conditions.

DIF: Recall REF: Central Nervous System Depressants (Ethyl Alcohol [Treatment]) | p. 261 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 17. Which of the following drugs may be used to reduce alcohol craving? a. Metronidazole b. Naltrexone c. Chlordiazepoxide d. Vitamin K ANS: B

Naltrexone (ReVia) is an oral opioid antagonist. Because naltrexone is partially effective in decreasing craving from alcohol, the logical conclusion is that alcohol stimulates some of the opioid receptors.

Naltrexone is used to reduce alcohol craving.

DIF: Recall REF: Central Nervous System Depressants (Ethyl Alcohol [Treatment]) | p. 261 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 18. Which drug is associated with a deficiency of coagulation factors II, VII, IX, and X after chronic

abuse? a. Ethyl alcohol b. Nicotine c. Cocaine d. Nitrous oxide ANS: A

Because of ethyl alcohol–induced hepatic failure, the liver is able to store less vitamin K, which is required for the synthesis of coagulation factors II, VII, IX, and X. The other agents do not produce a deficiency in these coagulation factors.

DIF: Recall REF: Central Nervous System Depressants (Ethyl Alcohol [Dental Treatment of the Alcoholic Patient]) | p.

262 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 19. Advanced periodontal disease, jaundice, and palmar erythema are signs of a. smokeless tobacco use. b. Wernicke encephalopathy. c. advanced alcoholic liver disease. d. chronic nitrous oxide use.

ANS: C

These three signs point to alcoholic’s poor oral hygiene, liver damage, and peripheral vasodilation.

Smokeless tobacco use would cause periodontal disease but not the other symptoms. Wernicke encephalopathy would cause amnesia. Chronic nitrous oxide use does not produce these signs.

DIF: Comprehension REF: Central Nervous System Depressants (Ethyl Alcohol) [Box 23.2: Signs of Advanced Alcoholic Liver Disease]) | p. 263 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 20. Nitrous oxide abuse a. can lead to physical dependence. b. is primarily seen in food service employees. c. can cause infertility. d. can cause myelocytosis.

ANS: C

Chronic use can cause mental dysfunction and infertility. Nitrous oxide use does not cause physical dependence. Abuse is primarily by dental personnel. Nitrous oxide causes myeloneuropathy, not myelocytosis.

DIF: Recall REF: Central Nervous System Depressants (Nitrous Oxide [Adverse Reactions]) | p. 264 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 21. Which drug syndrome produces symptoms resembling pernicious anemia? a. Chronic alcohol use disorder b. Chronic nitrous oxide use c. Opioid withdrawal d. Chronic tobacco use ANS: B

The neurologic deficiency seen with chronic nitrous oxide use is similar to that seen in pernicious anemia. Chronic alcohol use disorder, opioid withdrawal, and chronic tobacco use do not cause these symptoms.

DIF: Comprehension REF: Central Nervous System Depressants (Nitrous Oxide [Adverse Reactions]) | p. 264 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 22. Which agent produces a state described as a complete satiation of all drives? a. Ethyl alcohol b. Cocaine c. Nitrous oxide d. Morphine e. Methaqualone ANS: D

Opioids, such as morphine, elevate the user’s mood, cause euphoria, relieve fear and apprehension, and produce a feeling of peace and tranquility. They also suppress hunger, reduce sexual desire, and diminish the response to provocation. None of the other drugs mentioned produce the satiation of drives and sense of well-being that opioids can produce.

DIF: Recall OBJ: 2

REF: Central Nervous System Depressants (Opioid Analgesics) | p. 264 TOP: NBDHE, 6.0. Pharmacology

23. Which agent has a withdrawal syndrome characterized by yawning, rhinorrhea, and chills that alternate

with excessive sweating? a. Amphetamine b. Diazepam c. Nicotine d. Heroin ANS: D

The first signs of heroin withdrawal are yawning, lacrimation, rhinorrhea, and diaphoresis, followed by a restless sleep. With further abstinence, anorexia, tremors, irritability, weakness, and excessive gastrointestinal activity occur. The heart rate is rapid, blood pressure is elevated, and chills alternate with excessive sweating. Amphetamine withdrawal causes ravenous appetite, aching muscles, and long periods of sleep. Diazepam withdrawal causes insomnia, hyperthermia, and convulsions. Nicotine withdrawal causes drowsiness, headaches, and increased appetite.

DIF: Comprehension REF: Central Nervous System Depressants (Opioid Analgesics [Pattern of Abuse]) | p. 264 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 24. The triad of narcotic overdose is a. respiratory depression, pinpoint pupils, and coma. b. hyperactive behavior, dilated pupils, and cardiac arrhythmias. c. elevated blood pressure, blank stare, and rigidity. d. respiratory depression, cardiac depression, and sleep.

ANS: A

Respiratory depression, pinpoint pupils, and coma are key signs of opioid overdose. The other sets of signs are characteristic of amphetamine overdose, of phencyclidine overdose, and of sedative-hypnotic overdose, respectively.

DIF: Recall REF: Central Nervous System Depressants (Opioid Analgesics [Management of Acute Overdose and Withdrawal]) | p. 264 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 25. Prescribing for analgesia is best when treating a dental patient who abuses opioids. a. Tylenol #3 with codeine b. Vicodin c. Percocet d. nonsteroidal antiinflammatory drugs (NSAIDs) ANS: D

Alleviating the cause of the pain first and then prescribing NSAIDs for analgesia is best. Because an opioid abuser develops tolerance to the analgesic effects of any opioid, treating pain with opioids is ineffective and can cause a recovering addict to begin using opioids again.

DIF: Recall REF: Central Nervous System Depressants (Opioid Analgesics [Dental Implications]) | p. 265 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology

26. Dental health care workers should have heightened awareness of the issues of substance use disorder

because a. their coworkers may abuse drugs in the workplace. b. “shoppers” may interact with health care workers in an effort to obtain controlled substances. c. patients who abuse drugs intravenously are more likely to contract sexually transmitted or blood-borne diseases that are transmissible to the dental health care worker. d. dentist’s offices have prescription pads and abusable substances that need to be safely monitored. e. of all of the above.

ANS: E

Coworkers can be tempted by availability. “Shoppers” become very good at manipulating health care workers to give them what they want. Certain diseases that can be transmitted by use of needles for injections have a higher incidence in opioid abuse. All statements are true. Prescription pads should be kept in a locked drawer to prevent theft.

DIF: Application REF: Identifying the Substance User | p. 270 | The Impaired Dental Hygienist | p. 270 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 27. For which of the following agents does treatment of withdrawal involve replacement of the abused

drug with an equivalent drug, followed by gradual withdrawal of the equivalent drug? a. Opioid analgesics b. Sedative-hypnotics c. Alcohol d. All of the above e. None of the above ANS: D

Substitution followed by gradual withdrawal is a strategy used to manage several different types of addictions. The described regimen is an accepted one for all three of the drugs mentioned.

DIF: Comprehension REF: Central Nervous System Depressants (Ethyl Alcohol [Withdrawal]) | p. 260 | Central Nervous System Depressants (Opioid Analgesics [Management of Acute Overdose and Withdrawal]) | p. 265 | SedativeHypnotics (Management of Acute Overdose and Withdrawal) | p. 266 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 28. Signs and symptoms of an acute overdose of amphetamines include a. pinpoint pupils. b. hypothermia. c. diaphoresis. d. excessive salivation.

ANS: C

The patient may exhibit diaphoresis, hyperthermia, fine tremors, and hyperactive behavior. Oral adverse reactions include xerostomia and bruxism. Signs and symptoms of an acute overdose include dilated pupils, elevated blood pressure, rapid pulse, and cardiac arrhythmias.

DIF: Comprehension REF: Central Nervous System Stimulants (Amphetamines [Management of Acute Overdose and Withdrawal]) | p. 267 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 29. “Bath salts” are related to a. marijuana. b. opioid analgesics. c. amphetamines. d. lysergic acid diethylamide (LSD).

ANS: C

Legislation was signed making mephedrone and 4-methylenedioxypyrovalerone (MDPV) illegal in the United States. Bath salts can cause euphoria, increased sociability, increased heart rate, and elevated blood pressure. They also cause hallucinations, paranoia, agitation, delirium, psychosis, and violent behavior. “Bath salts” refer to a growing group of drugs containing one or more synthetic chemicals related to cathinone, an amphetamine-like substance found in the Khat plant. This synthetic amphetamine-like substance is called “bath salts” because its crystalline powder dose form looks like bath salts.

DIF: Recall REF: Central Nervous System Stimulants (Amphetamines [Pattern of Abuse]) | pp. 266-267 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 30. What is the primary reason why treatment can be dangerous with an active methamphetamine user? a. The person may be psychotic. b. The person may become paranoid and bite the operator. c. The use of local anesthetic can intensify the cardiac effects of meth. d. The sound of the dental drill can cause the patient to become agitated.

ANS: C

To treat patients with meth mouth, the dentist or dental hygienist should prescribe fluoride to fight tooth decay and prevent caries and treat xerostomia as well. The cardiac effects associated with local anesthetic and vasoconstrictor can intensify the cardiac effects of meth.

DIF: Recall REF: Central Nervous System Stimulants (Amphetamines [Pattern of Abuse]) | p. 266 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 31. Each of the following is true of marijuana use EXCEPT one. Which is the EXCEPTION? a. A common adverse reaction is a panic attack. b. The agent can cause xerostomia. c. Physical dependence, tolerance, and withdrawal symptoms are common. d. Marijuana is effective as an antiemetic.

ANS: C

Physical dependence, tolerance, and withdrawal symptoms are rare. Marijuana can cause panic attacks and xerostomia. It also has recognized antiemetic activity.

DIF: Comprehension

REF: Psychedelics (Hallucinogens) (Marijuana) | p. 269 | Psychedelics (Hallucinogens) (Marijuana [Medical Marijuana]) | p. 269 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 32. What is “spice” or “K-2”? a. A designer drug created by spraying natural herbs with synthetic chemicals that b. c. d. e.

produce psychoactive effects similar to cannabis A method of smoking oregano to get a hallucinogenic effect The stems of the hemp plant rather than the leaves A version of phencyclidine (PCP) A British female pop group or a brand of snow skis

ANS: A

These designer drugs are marketed as “safe,” legal alternatives to marijuana. The Drug Enforcement Agency has declared the five active chemical substances most frequently abused as Schedule I. The remaining choices are not chemicals associated with spice or K-2.

DIF: Recall OBJ: 5

REF: Psychedelics (Hallucinogens) (Marijuana [Synthetic Marijuana]) | p. 269 TOP: NBDHE, 6.0. Pharmacology

33. According to Substance Abuse and Mental Health Administration, binge drinking is 5 or more drinks

on the same occasion at least once in which period of time? a. One week b. One month c. Three months d. Six months e. One year ANS: B

Most Americans are moderate drinkers, which is defined as 1 drink per day for women and up to 2 drinks per day for men. According to Substance Abuse and Mental Health Administration, binge drinking is 5 or more drinks on the same occasion at least once in a 30-day time period.

DIF: Application REF: Central Nervous System Depressants (Ethyl Alcohol [Alcohol Use Disorder]) | p. 261 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 34. Acamprosate (Campral) is used to treat a. cocaine addiction. b. methamphetamine addiction. c. mescaline addiction. d. alcohol use disorder. e. heroin addiction.

ANS: D

Acamprosate appears to work by modulating/normalizing alcohol-disrupted brain activity, particularly in the GABA and glutamate neurotransmitter systems that would otherwise stimulate withdrawal.

Acamprosate (Campral) is the newest drug approved by the Food and Drug Administration to treat Alcohol Use Disorder.

DIF: Recall

REF: Central Nervous System Depressants (Ethyl Alcohol [Treatment]) | p. 262 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 35. The 2016 report of the National Survey on Drug Use and Health reported that what percentage of

people that have misused opioid pain medication obtained it from a friend or relative? a. 13% b. 23% c. 33% d. 43% e. 53% ANS: E

The survey also reported that 11.5 million Americans engaged in misuse of opioid medications over 1 month. The 2016 report of the National Survey on Drug Use and Health reported that 53% of persons who misused opioid pain medication got it from a friend or relative and 37.5% got it from a doctor.

DIF: Recall REF: Central Nervous System Depressants (Opioid Analgesics [Prescription Opioids]) | p. 265 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 36. About how many people over the age of 12 had Stimulant Use Disorder in 2016 due to cocaine? a. 167,000 b. 367,000 c. 567,000 d. 767,000 e. 867,000 ANS: E

The CNS stimulants include cocaine, the amphetamines, caffeine, and nicotine. Another 684,000 had Stimulant Use Disorder due to methamphetamine.

DIF: Recall OBJ: 3

REF: Central Nervous System Stimulants | p. 266 TOP: NBDHE, 6.0. Pharmacology

37. Which age group has the highest rate of current use of tobacco products in America? a. Young adults aged 18 to 24 b. Adults aged 25 to 44 c. Adults aged 45 to 64 d. Adults aged 65 or older ANS: C

Approximately 14% of Americans over the age of 18 smoke. Young adults aged 18 to 24 had the lowest rate of current use of a tobacco product (8%), followed by adults 65 years of age (8.2%) then 25–44 (16.7%), and by those aged 45–64 (17%) based upon 2019 data. In 2020, 23.6% of high school students and 6.7% of middle school students used tobacco products.

DIF: Comprehension REF: Central Nervous System Stimulants (Tobacco [Pattern of Abuse]) | p. 267 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology

38. Smoking tobacco with a hookah is not as dangerous as smoking cigarettes. Because the tobacco passes

through water less smoke is inhaled than with smoking cigarettes. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false. d. The first statement is false, the second statement is true.

ANS: B

Even though the tobacco passes through water before it is inhaled it still contains high levels of toxic agents. The water pipe delivers nicotine to the body and can lead to dependence. People inhale 100– 200 times the amount of smoke in a 1-hour hookah session than by smoking one cigarette.

DIF: Comprehension REF: Central Nervous System Stimulants (Tobacco [Smokeless Tobacco]) | p. 268 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 39. E-cigarettes do not inhale the tars and other substances found in regular cigarettes. Children, teenagers,

and pregnant women should not use them. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: A

According to 2016 statistics, 2 million middle and high school students used e-cigarettes. Of these students, 81% said that the different flavorings were the primary reason for use. A person that uses an e-cigarette only inhales nicotine. Nicotine is harmful to the developing brain.

DIF: Comprehension REF: Central Nervous System Stimulants (Tobacco [Smokeless Tobacco]) | p. 268 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology MULTIPLE RESPONSE 1. Which of the following are true of nicotine in smoking tobacco and smokeless tobacco? (Select all that

apply.) a. There are many other components of tobacco smoke that are harmful in addition to nicotine. b. About one-half of the adult American population smokes cigarettes. c. Chronic use of tobacco is causally related to many serious diseases, including coronary artery disease and oral and lung cancers. d. Smokeless tobacco is a safe alternative to smoking cigarettes.

ANS: A, C

The central nervous system (CNS)-active component of tobacco is nicotine, but a large number of components of the gaseous phase of tobacco smoke contribute to its undesirable effects: carbon monoxide, nitrogen oxides, volatile nitrosamines, hydrogen cyanide, volatile hydrocarbons, and many others. Smoking tobacco is related to many serious diseases. Approximately 26% of Americans over the age of 12 smokes. Oral mucosal changes associated with smokeless tobacco include precancerous lesions.

DIF: Application REF: Central Nervous System Stimulants (Tobacco [Nicotine]) | p. 267 | Central Nervous System Stimulants (Tobacco [Pattern of Abuse]) | p. 268 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Abuse is the use of a drug for a disease state in a way considered inappropriate.

ANS: F

Misuse is the use of a drug for a disease state in a way considered inappropriate.

DIF: Recall OBJ: 1

REF: General Considerations (Definitions) | p. 258 TOP: NBDHE, 6.0. Pharmacology

2. During drug withdrawal, symptoms appear that are opposite of the symptoms of drug use.

ANS: T

For instance, excessive parasympathetic action such as diarrhea, lacrimation, and piloerection (“cold turkey”) can occur when withdrawing from the opioids.

DIF: Recall OBJ: 1

REF: General Considerations (Physical Dependence) | p. 259 TOP: NBDHE, 6.0. Pharmacology

3. Drug withdrawal from sedative-hypnotic agents can be more life threatening than withdrawal from

opioids.

ANS: T

Sedative-hypnotic agent withdrawal can lead to life-threatening seizures.

DIF: Application REF: Central Nervous System Depressants (Sedative-Hypnotics [Management of Acute Overdose and Withdrawal]) | p. 266 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. Bupropion is an effective treatment for alcohol use disorder.

ANS: F

Bupropion is used for tobacco cessation.

DIF: Recall OBJ: 4

REF: Central Nervous System Stimulants (Tobacco [Bupropion]) | p. 268 TOP: NBDHE, 6.0. Pharmacology

5. Chewing tobacco will not lead to cancer because the tobacco is not burned nor the smoke inhaled.

ANS: F

Smokeless tobacco use poses significant oral health hazards, including cancer.

DIF: Recall REF: Central Nervous System Stimulants (Tobacco [Smokeless Tobacco]) | p. 268 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology

Chapter 24: Natural/Herbal Products and Dietary Supplements Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. Which statements are true about natural or herbal substances in the United States? a. Herbal products marketed as dietary supplements are not required to comply with

safety and efficacy regulations imposed on drug products. b. Manufacturers cannot claim to cure conditions, but they can claim to improve

structure or function. c. The Food and Drug Administration (FDA) can allow a qualified health claim if

scientific evidence exists to support the claim. d. Because a prescription is not necessary for their use, most patients do not consider

natural products or dietary supplements to be medicine. e. All of the above are true. f. Only A and C are true.

ANS: E

Although concerns exist about the safety of natural or herbal substances in the United States, manufacturers do not have to comply with FDA safety and efficacy regulations imposed on drug products. All of the other statements are true as well; the dental health care worker should be knowledgeable about these products.

DIF: Application REF: Introduction | p. 272 | Limited Regulation (Dietary Supplement Health and Education Act) | p. 272 OBJ: 1 | 2 TOP: NBDHE, 6.0. Pharmacology 2. The FDA has performed much of the research and advanced the knowledge about herbal products and

supplements. The German Federal Health Agency established the German Commission E to review and analyze world literature on plant-based products. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: D

Before 1994, the FDA attempted to propose stricter regulations for the herbal supplement industry; however, aggressive lobbying by the dietary supplement industry and thousands of letters from the general public to Congress blocked the proposed regulation. The German Commission E was originally established by the German Federal Health Agency to review and analyze the world literature on plant-based products. The FDA considers natural products to be dietary supplements; therefore, these manufacturers do not have to meet the same standards as drug manufacturers to prove efficacy in treating or preventing a specific disease, nor can they make that claim. The German Commission E (an expert panel composed of physicians, pharmacists, pharmacologists, and biostatisticians) has contributed much of what is known about herbal products or supplements.

DIF: Comprehension REF: Introduction | p. 272 | Limited Regulation (Dietary Supplement Health and Education Act) | p. 265 OBJ: 1 | 2 TOP: NBDHE, 6.0. Pharmacology 3. Herbal products in the United States are regulated by which governmental agency? a. Federal Trade Commission b. Food and Drug Administration (FDA) c. Environmental Protection Agency d. Dietary Supplement and Education Act (DSHEA) e. US Pharmacopeia ANS: D

Before this act, the manufacturer had to prove that an herbal product was safe and effective. Today, the FDA must prove that the product is unsafe. Herbal products are regulated by the Dietary Supplement and Education Act, which exempts vitamins, minerals, and botanical products from FDA regulation unless they are proven unsafe.

DIF: Recall REF: Limited Regulation (Dietary Supplement Health and Education Act) | p. 273 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. Many consumers consider herbal products to be nontoxic or side effect free because they are often

called “natural” remedies. Most herbal products cause no adverse effects and drug interactions. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Dental hygienists should be sure to ask questions about herbal or dietary supplement use because many patients will fail to mention them, and these products can have an adverse effect on dental treatment.

Although consumers tend to consider natural products safe and free of adverse reactions, a large number of herbal products can cause adverse effects and drug interactions.

DIF: Comprehension REF: Safety of Herbal and Nutritional Products | p. 273 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 5. An increased risk of bleeding can occur when

drugs or anticoagulants. a. Ma huang

is taken in conjunction with antiplatelet

b. c. d. e. f. g.

Garlic Ginkgo biloba Feverfew St. John’s wart All of the above B, C, and D

ANS: G

Garlic, Ginkgo biloba, and feverfew can increase the risk for bleeding when taken in conjunction with antiplatelet drugs or anticoagulants. It is important that the dental professional be aware if patients are taking these agents and be knowledgeable about their interactions and adverse effects. Ma huang contains ephedrine and can increase heart rate when combined with sympathomimetic drugs. St. John’s wart can induce hepatic enzymes and increase the metabolism of drugs such as local and general anesthetics.

DIF: Comprehension REF: Drug Interactions | p. 273 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 6. The FDA introduced Good Manufacturing Practice standards to ensure that dietary supplements are

free of adulterants, contaminants, and impurities and that the labels accurately depict the contents of the package. This testing in mandatory and is enforced by the FDA. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

In 2007, the GMP standards mandated that manufacturers establish quality-control procedures. The FDA introduced good Manufacturing Practice (GMP) standards in 2003 to ensure that dietary supplements are devoid of adulterants, contaminants, and impurities and that package labels accurately reflect the identity, purity, quality, and strength of the ingredients that are actually inside the package.

However, testing is left to the discretion of the manufacturer, and the FDA does not inspect all manufacturing facilities for compliance. Only manufacturers that have demonstrated unsafe practices are subject to more frequent inspections.

DIF: Comprehension REF: Good Manufacturing Practice | p. 275 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 7. Each of the following is a problem with herbal supplements EXCEPT one. Which is the

EXCEPTION? a. Information about drug interactions with herbal supplements is lacking. b. The purity and potency of these products are closely regulated. c. Dosage is not standardized. d. Package labeling is often incomplete or inaccurate. e. The product may contain more than one active ingredient.

ANS: B

Herbal products can interact with conventional drugs, with disastrous results. Until herbal products are standardized and labeling is accurate and comprehensive, it will be difficult to obtain accurate information on possible interactions. Unfortunately, along with all of the other problems associated with herbal supplements, the purity and potency of herbal supplements are not well regulated.

DIF: Comprehension REF: Drug Interactions | p. 274 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 8. Which herbal supplement products have been proven effective in protecting against plaque and

gingivitis? a. Acemannan hydrogel (extract of aloe vera) b. Essential oil mouth rinse c. Oil of cloves (eugenol) d. Triclosan e. Xylitol f. B and D only ANS: F

More than 20 essential oils in mouth rinses have received the American Dental Association Seal of Acceptance for protection against plaque and gingivitis. One triclosan-containing product has received the American Dental Association’s Seal of Acceptance for its antigingivitis effect. Acemannan hydrogel (an extract of aloe vera) has an immunomodulating property that is available in an over-thecounter (OTC) topical patch that reduces the duration of aphthous ulcers. Oil of cloves (eugenol) has been used for many years as a topical analgesic for dental pain and is used widely by dental professionals. There are no published trials documenting its efficacy. Xylitol is a naturally occurring sweetener derived from plants. It is comparable in sweetness to sucrose but cannot be metabolized by Streptococcus mutans to form acids, so it has antibacterial and cariostatic effects.

DIF: Comprehension REF: Herbal Supplements Used in Oral Health Care (Essential Oil Mouth Rinse) | p. 276 | Herbal Supplements Used in Oral Health Care (Triclosan) | p. 276 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 9. Which is the mechanism of action of xylitol for its antibacterial and cariostatic effects? a. Direct bactericidal effect on Streptococcus mutans b. Inhibition of the ability of S. mutans to adhere and multiply in plaque c. Inability to be metabolized by S. mutans as a nutrient source d. B and C only e. All of the above ANS: D

Xylitol consumption reduces S. mutans levels, yielding antibacterial and cariostatic effects. Xylitol cannot be metabolized by S. mutans as a nutrient source to produce acids. Xylitol’s antibacterial effects inhibit the ability of microbes to adhere and grow in plaque.

DIF: Comprehension REF: Herbal Supplements Used in Oral Health Care (Xylitol) | p. 276 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology

10. Oil of cloves has been used in dentistry for many years as a topical analgesic for dental pain. Extensive

clinical trials have confirmed its efficacy. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

The mechanism of action is unknown, but it is believed that pulpal nerves are somehow affected to reduce pain. Oil of cloves (eugenol) has been used in dentistry for topical analgesia for relief of dental pain, but no published clinical trials have confirmed its efficacy.

DIF: Comprehension REF: Herbal Supplements Used in Oral Health Care (Oil of Cloves (Eugenol)) | p. 276 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 11. Which is true of eugenol? a. Used in mouth rinses containing thymol, eucalyptol, and menthol. b. Extract of aloe vera plant leaf used to treat aphthous ulcers. c. Historically used in dentistry as a topical analgesic for dental pain. d. Herbal-based product that significantly reduces plaque and gingivitis. e. Naturally occurring sweetener with an anticariogenic effect.

ANS: C

Oil of cloves (eugenol) has been used in dentistry for topical analgesia for relief of dental pain, but no published clinical trials have confirmed its efficacy. The mechanism of action is unknown, but it is believed that pulpal nerves are somehow affected to reduce pain. Essential oils are mouth rinses containing thymol, eucalyptol, and menthol. Acemannan hydrogel is an extract of aloe vera plant leaf used to treat aphthous ulcers. Triclosan is an herbal-based product that significantly reduces plaque and gingivitis. Xylitol is a naturally occurring sweetener with an anticariogenic effect.

DIF: Comprehension REF: Herbal Supplements Used in Oral Health Care (Oil of Cloves (Eugenol)) | p. 276 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology 12. Each of the following is true of the FDA Food Safety and Modernization Act of 2010 EXCEPT one.

Which is the EXCEPTION? a. It provides the FDA with mandatory recall authority for all foods. b. It requires the FDA to issue New Dietary Ingredients guidance. c. It expands the facility registration obligations. d. It requires the manufacturer to prove that an herbal product is safe and effective.

ANS: D

The FDA Food Safety and Modernization Act of 2010 provides the FDA with mandatory recall authority for all foods, including dietary supplements, it expands the facility registration obligations, and it requires the FDA to issue New Dietary Ingredients guidance. This was true before the Dietary Supplement Health and Education Act (DSHEA) was passed. The DSHEA exempts vitamins, minerals, and botanical products from meaningful FDA regulation. Before that, the manufacturer had to prove that an herbal product was safe and effective. Today, the FDA must prove that the product is unsafe.

DIF: Comprehension REF: Limited Regulation (Dietary Supplement Health and Education Act) | p. 273 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. The Adverse Events Reporting law requires reporting of “serious” adverse events for a. both over-the-counter drugs and dietary supplements. b. over-the-counter drugs but not dietary supplements. c. dietary supplements but not over-the-counter drugs. d. neither over-the-counter drugs nor dietary supplements.

ANS: A

Serious events must be reported for both. In December of 2007 the Adverse Events Reporting law amended the Federal Food, Drug, and Cosmetic Act to require that both be reported.

DIF: Comprehension REF: Safety of Herbal and Nutritional Products | p. 273 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology

Chapter 25: Oral Conditions and Their Treatment Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. A patient presents with an oral ulcer that begins at an interdental papillae. The condition most likely is a. herpetic gingivostomatitis. b. acute necrotizing ulcerative gingivitis (ANUG). c. aphthous stomatitis. d. pericoronitis.

ANS: B

ANUG is a spreading ulcer associated with a distinctive odor; the ulcerated area begins at the interdental papillae. Herpetic gingivostomatitis and aphthous stomatitis are ulcerative conditions in which ulcers may coalesce rather than spread from the interdental papillae. Pericoronitis is inflammation and bacterial infection around the crown of the tooth.

DIF: Comprehension REF: Infectious Lesions (Acute Necrotizing Ulcerative Gingivitis) | p. 278 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 2. Antibiotics should be considered for the treatment of ANUG a. for all patients. b. for all adult patients but not for children. c. only if the patient is running a fever. d. only if the patient is immunocompromised or if evidence of systemic involvement

exists.

ANS: D

They should be considered only if the patient is immunosuppressed or if evidence of systemic involvement exists. Antibiotics useful for the immunosuppressed patient with ANUG include penicillin VK and metronidazole. If pain or an elevated temperature accompanies ANUG, then aspirin or acetaminophen can be recommended. If eating is difficult, food supplements may be used instead of meals. Vitamin supplementation is useful only if the patient has a vitamin deficiency. The remaining choices are not correct.

DIF: Comprehension REF: Infectious Lesions (Acute Necrotizing Ulcerative Gingivitis) | p. 278 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. Which of the following is recommended as a rinse for ANUG? a. Phenol b. Essential oil c. Chlorhexidine gluconate d. Hydrogen peroxide ANS: C

Topical chlorhexidine gluconate, active against gram-positive and gram-negative organisms, and Candida organisms, is used as a rinse for ANUG. The majority of ANUG cases respond dramatically to local treatment (oral prophylaxis with scaling). ANUG has both bacteriologic (spirochetes) and environment (stress, debilitation) factors. Mouthwashes, such as hydrogen peroxide, or saline rinses assist by their flushing action. Chlorhexidine is active against both gram-positive and gram-negative bacteria and has some antifungal activity.

DIF: Recall OBJ: 1 4. Approximately a. 10 b. 20 to 30 c. 50 to 60 d. 80 to 90

REF: Infectious Lesions (Acute Necrotizing Ulcerative Gingivitis) | p. 278 TOP: NBDHE, 6.0. Pharmacology

% of the adult population has been exposed to herpes simplex virus (HSV).

ANS: D

Approximately 80% to 90% of the adult population has been exposed to HSV. HSV-1 is involved in most oral lesions, and transmission is usually not sexual. HSV-2 is usually responsible for genital herpes and is transmitted sexually. Both HSV-1 and HSV-2 can spread to other parts of the body, for example, the eyes, genitals, and fingers (herpetic whitlow). The other choices do not correctly represent the percentage of the adult population that has been exposed to herpes simplex virus (HSV).

DIF: Recall OBJ: 1

REF: Infectious Lesions (Herpes Infections) | p. 278 TOP: NBDHE, 6.0. Pharmacology

5. Acyclovir ointment is the treatment of choice for primary and recurrent herpes labialis in

immunocompetent patients. It is more effective than acyclovir cream in recurrent herpes. a. Both the statement and the reason are correct and related. b. The statements and the reason are both correct but not related. c. The statement is correct, but the reason is not.

d. The statement is not correct, but the reason is accurate. e. Neither the statement nor the reason is correct.

ANS: E

Oral acyclovir is preferred over the ointment for primary herpes labialis in the immunocompetent patient, although the ointment does have some efficacy in this condition. The ointment is not effective in immunocompetent patients with recurrent herpes. The cream does appear to be more effective than the ointment in this patient population. The other choices are not correct.

DIF: Application OBJ: 1

REF: Infectious Lesions (Herpes Infections [Acyclovir]) | p. 280 TOP: NBDHE, 6.0. Pharmacology

6. The following agents are useful in the treatment of oral herpes lesions except one. Which one is the

exception? a. Diphenhydramine liquid b. Acyclovir c. Corticosteroids d. Viscous lidocaine e. Sodium carboxymethylcellulose ANS: C

Corticosteroids are contraindicated in patients with herpes because they suppress the cellular immunity that inhibits viral infections. Diphenhydramine, viscous lidocaine, and carboxymethylcellulose are options for the symptomatic treatment of oral herpes infections. Acyclovir has direct activity against the viral infection.

DIF: Application OBJ: 1

REF: Infectious Lesions (Herpes Infections [Treatment]) | p. 279 TOP: NBDHE, 6.0. Pharmacology

7. Cheilosis can result from deficiencies of vitamins a. B1 and B2. b. B2 and B6. c. B6 and B12. d. B9 and B12.

ANS: B

Cheilosis can result from deficiencies of vitamins B2 and B6. Vitamin B supplements would be useful but only if a vitamin deficiency exists. Although it is rare, cheilosis can result from deficiencies of two of the B vitamins.

DIF: Comprehension REF: Infectious Lesions (Angular Cheilitis/Cheilosis) | p. 282 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

8. Alveolar osteitis, or “dry socket,” occurs in 2% to 3% of all tooth extractions, most commonly in the a. b. c. d.

region. mandibular incisor mandibular molar maxillary incisor maxillary molar

ANS: B

Alveolar osteitis, or “dry socket,” occurs in 2% to 3% of all tooth extractions, most commonly in the mandibular molar region. The incidence is considerably higher here than in other areas. Alveolar osteitis is thought to be caused by loss or necrosis of the blood clot that has formed in the extraction site, exposing the underlying bone. Dry socket is associated with one particular area of the oral cavity.

DIF: Comprehension REF: Infectious Lesions (Alveolar Osteitis) | p. 282 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 9. The following statements are true of alveolar osteitis except which one? a. Alveolar osteitis occurs in 2% to 3% of all extractions. b. Cigarette smoking increases its likelihood. c. Alveolar osteitis is attributed to loss or necrosis of the blood clot at the extraction

site. d. Antibiotic prophylaxis is recommended. e. Diabetes is a predisposing factor.

ANS: D

Most literature does not recommend the use of antibiotic prophylaxis. However, treatment with antibiotics is warranted if an infection is detected. The other choices are all true of alveolar osteitis.

DIF: Comprehension REF: Infectious Lesions (Alveolar Osteitis) | p. 282 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 10. Recurrent aphthous stomatitis (RAS), which is sometimes referred to as a canker sore, is a common

oral lesion occurring in approximately a. 10 b. 20 c. 30 d. 40

% of the population.

ANS: B

Recurrent aphthous stomatitis occurs in approximately 20% of the population. It is seen after 20 years of age and has an unknown etiology, although an involvement of the immune system is suspected.

RAS presents clinically as a few small to many large ulcers. These ulcers can even coalesce into giant ulcers. The other choices do not correctly depict the percentage of the population in which RAS occurs.

DIF: Recall OBJ: 2

REF: Immune Reactions (Recurrent Aphthous Stomatitis) | p. 282 TOP: NBDHE, 6.0. Pharmacology

11. The etiology of aphthous stomatitis involves an immunologic component in which a significant role is

played by a. B lymphocytes. b. T lymphocytes. c. plasma cells. d. monocytes.

ANS: B

T lymphocytes play a significant role. A decreased ratio of T-helper (CD4+) cells to Tsuppressor/cytotoxic (CD8+) cells can be seen. An increase in the CD8 cells is seen. The oral mucosa is destroyed by lymphocytes. The remaining choices do not identify the immunologic component that is thought to play a role in the etiology of aphthous stomatitis.

DIF: Recall OBJ: 2

REF: Immune Reactions (Recurrent Aphthous Stomatitis) | p. 282 TOP: NBDHE, 6.0. Pharmacology

12. Which of the following conditions involves a focal immune dysfunction in which a decreased ratio of

T-helper to T-suppressor/cytotoxic cells can be seen? a. Alveolar osteitis b. Angular cheilitis c. Acute necrotizing ulcerative gingivitis (ANUG) d. Recurrent aphthous stomatitis (RAS) e. Geographic tongue ANS: D

RAS is a disorder in which an increase in CD8 cells is seen and the oral mucosa is destroyed by lymphocytes. Alveolar osteitis, angular cheilitis, and ANUG are all associated with pathogenic organisms, whereas geographic tongue is of unknown etiology, although some forms may be immune related.

DIF: Comprehension REF: Immune Reactions (Recurrent Aphthous Stomatitis) | p. 282 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 13. The treatment of recurrent aphthous stomatitis (RAS) may include any of the following except which

one? a. Corticosteroids b. Topical lauryl sulfate c. Diphenhydramine d. Amlexanox ANS: B

Sodium lauryl sulfate is an ingredient in many over-the-counter oral hygiene products, such as toothpastes, and may be the root cause of RAS. Corticosteroids have been the mainstay of therapy for RAS. Amlexanox decreases the duration of the ulcers. Diphenhydramine provides symptomatic relief of the pain associated with RAS. DIF: Comprehension REF: Immune Reactions (Recurrent Aphthous Stomatitis) | p. 282 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 14. Which subtype of lichen planus is characterized by a white, lacelike pattern intersecting to form a

reticular pattern? a. Striated b. Plaque-like c. Erosive d. Hypertrophic e. Idiopathic

ANS: D

The white, lacelike pattern is characteristic of hypertrophic lichen planus. Striated, plaque-like, and erosive lichen planus do not have the lacelike characteristic. Most lichen planus is idiopathic (of unknown etiology), although viruses, autoimmunity, and hypersensitivity are often suspected.

DIF: Recall OBJ: 2

REF: Immune Reactions (Lichen Planus) | p. 283 TOP: NBDHE, 6.0. Pharmacology

15. Glossopyrosis is another term for a. geographic tongue. b. pericoronitis. c. Vincent infection. d. bald tongue. e. burning tongue.

ANS: E

Gloss = tongue, and pyro = burn. Geographic tongue produces burning with certain foods but has distinct lesions, whereas burning tongue may or may not have observable lesions. Pericoronitis involves inflammation of gingival tissue, Vincent infection is another term for ANUG, and bald tongue is characterized by atrophy of the glossal papillae, resulting in a smooth tongue.

DIF: Recall REF: Miscellaneous Oral Conditions (Burning Mouth or Tongue Syndrome) | p. 283 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 16. Pericoronitis most commonly applies to partially erupted a. incisors. b. premolars. c. first molars. d. third molars.

ANS: D

The term pericoronitis most commonly applies to partially erupted third molars. It refers to an inflammatory response that is produced when food and bacteria become trapped between the operculum and the tooth. Periodontal pockets can become painful and swell. If the condition is observed early in its course, debridement with saline irrigation and the use of warm saline rinses will rectify the situation. Pericoronitis is strongly associated with one of these types of teeth.

DIF: Recall OBJ: 3

REF: Inflammation (Pericoronitis) | p. 284 TOP: NBDHE, 6.0. Pharmacology

17. Long-term exposure of the lip to a. lipstick or lip gloss b. the sun c. alcohol d. cold wind ANS: B

can cause irreversible tissue changes known as actinic cheilitis.

Long-term exposure of the lip to the sun can cause irreversible tissue changes known as actinic cheilitis. These sun-related changes occur near the vermilion border of the lips and can progress to malignancy. The remaining choices are not associated with the development of actinic cheilitis.

DIF: Recall OBJ: 3

REF: Inflammation (Actinic Lip Changes) | p. 284 TOP: NBDHE, 6.0. Pharmacology

18. Actinic lip changes, if keratotic, are best treated with a. sunscreen with a sun protection factor of 15 or greater. b. acyclovir. c. 5-fluorouracil (5-FU). d. topical steroids. e. diphenhydramine.

ANS: C

Keratotic changes may be precancerous and are best treated with an antineoplastic agent such as 5-FU. Sunscreen will not reverse the keratosis. Acyclovir is an antiviral and also ineffective for this condition. Topical steroids may be used to offset the adverse effects of 5-FU but are not a treatment for the condition. Diphenhydramine is also not an effective treatment for this condition.

DIF: Recall OBJ: 3

REF: Inflammation (Actinic Lip Changes) | p. 284 TOP: NBDHE, 6.0. Pharmacology

19. Each of the following is a method of treatment for xerostomia except one. Which is the exception? a. Change the medication or reduce the dose. b. Prescribe an anticholinergic agent to stimulate an increase in saliva. c. Prescribe artificial saliva. d. Use fluoride trays and gels to counteract the formation of caries. e. Use water or sugarless gum instead of gums, hard candies, and beverages

containing sugar.

ANS: B

Cholinergics, not anticholinergics, stimulate an increase in saliva. Changing medication, if feasible, gets to the root of the problem. Artificial saliva can be used in the absence of adequate secretion of natural saliva. Enhanced anticaries treatments and reduction of caries-promoting habits are also effective.

DIF: Comprehension REF: Drug-Induced Oral Side Effects (Xerostomia) | p. 284 TOP: NBDHE, 6.0. Pharmacology 20. Pilocarpine is a(n) a. adrenergic b. antiadrenergic c. cholinergic d. anticholinergic ANS: C

OBJ: 4

agent that produces an increase in saliva.

Pilocarpine is a cholinergic agent that produces an increase in saliva. Certain drugs may produce an increase in saliva termed sialosis, sialism, or sialorrhea. Adrenergic and anticholinergic agents have similar features. Adrenergic stimulation causes peripheral vasoconstriction to shunt blood to core muscles, dilated pupils to gather more information, increased cardiac output, relaxation of bronchiolar smooth muscle, and xerostomia. Cholinergic and antiadrenergic agents, in excess, produce salivation, lacrimation, urination, and defecation (SLUD).

DIF: Recall OBJ: 4

REF: Drug-Induced Oral Side Effects (Xerostomia) | p. 284 TOP: NBDHE, 6.0. Pharmacology

21. Gingival enlargement is a side effect of some drugs. Corticosteroids are used for the treatment of this

condition. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Many types of drugs are associated with gingival enlargement. The most common three are phenytoin, cyclosporine, and calcium channel blockers. Corticosteroids have not been shown to be effective in treating gingival enlargement. Substituting or discontinuing the drug and scrupulous personal hygiene are common approaches to limiting this condition. Gingival enlargement can occur in relation to several drug groups. Corticosteroids are used for many oral lesions, especially those with a component of inflammation or immune response. Although it is generally considered to be gingival hyperplasia, gingival enlargement can also be due to hypertrophy as well. Gingivoplasty or gingivectomy may be required to reshape the gingival tissue. It may need to be repeated periodically.

DIF: Application REF: Drug-Induced Oral Side Effects (Gingival Enlargement) | p. 287 | Agents Commonly Used to Treat Oral Lesions (Corticosteroids) | p. 287 OBJ: 4|5 TOP: NBDHE, 6.0. Pharmacology 22. Chlorhexidine causes intrinsic discoloration of the teeth, whereas stannous fluoride causes extrinsic

discoloration. a. Both parts of the statement are true. b. Both parts of the statement are false. c. The first part of the statement is true; the second part is false. d. The first part of the statement is false; the second part is true.

ANS: D

Similar to stannous fluoride, chlorhexidine causes extrinsic discoloration. Extrinsic stain originates from or on the outside following tooth eruption. Intrinsic stain is from within the tooth and can occur both prior to and following eruption.

DIF: Comprehension REF: Drug-Induced Oral Side Effects (Box 25.1: Oral Side Effects of Drugs) | p. 285 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 23. Which of the following agents is associated with gingival enlargement? a. Chlorhexidine

b. c. d. e.

Cyclosporine Angiotensin-receptor blocker Clindamycin Cyclobenzaprine

ANS: B

Cyclosporine is well documented to cause gingival enlargement. Chlorhexidine is associated with discoloration, clindamycin is associated with erythema multiforme, and cyclobenzaprine is associated with xerostomia. Some angiotensin-receptor blockers may alter taste.

DIF: Comprehension REF: Drug-Induced Oral Side Effects (Gingival Enlargement) | p. 287 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 24. Most cases of osteonecrosis of the jaw (ONJ) are associated with a. infection. b. cancer therapy. c. bisphosphonate therapy. d. use of steroids.

ANS: C

Osteonecrosis of the jaw (ONJ) occurs when the jaw bone is exposed and begins to starve because of a lack of blood flow to the area. The majority of cases of ONJ occur with intravenous bisphosphonate therapy. Fewer cases are reported in those patients taking bisphosphonates for the treatment of osteoporosis. ONJ is associated with cancer therapy, including radiation, infection, steroid use, and bisphosphonate therapy.

DIF: Recall OBJ: 4

REF: Drug-Induced Oral Side Effects (Osteonecrosis of the Jaw) | p. 287 TOP: NBDHE, 6.0. Pharmacology

25. According to the Centers for Disease Control, a patient with active herpetic lesions should receive

which type of dental care? a. Any dental restorative work or periodontal care is fine. b. Periodontal care but not restorative work. c. Direct restorative work (amalgam, composite) and routine prophylaxis. d. Routine prophylaxis only. e. Emergency dental care or treatment for the lesions only.

ANS: E

All other care should be delayed until the lesions have healed. Herpetic whitlow for the operator is not so much a concern since the advent of gloves; however, the lesions can spread on the patient due to tissue manipulation. Emergency dental care or treatment for the lesions is advised by the CDC. Lip pulling, a rubber dam, or biting an anesthetized lip can precipitate a herpetic outbreak.

DIF: Application OBJ: 1

REF: Infectious Lesions (Herpes Infections) | p. 279 TOP: NBDHE, 6.0. Pharmacology

26. HSV-1 is involved in most a. oral; not sexual b. oral; sexual

lesions and transmission is usually

.

c. genital; not sexual d. genital; sexual ANS: A

Both HSV-1 and HSV-2 can spread to other areas of the body, for example, the eyes, genitals, and fingers. HSV-2 is usually responsible for genital herpes and is transmitted sexually.

DIF: Comprehension REF: Infectious Lesions (Herpes Infections) | p. 278 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 27. Which antiviral agent is available without a prescription? a. Acyclovir b. Valacyclovir c. Penciclovir d. Docosanol e. Famciclovir ANS: D

Docosanol (Abreva) is available as a topical 10% cream. It should be applied at the first sign of symptoms. Acyclovir, valacyclovir, penciclovir, and famciclovir all require a prescription.

DIF: Recall OBJ: 1

REF: Infectious Lesions (Herpes Infections [Docosanol (Abreva)]) | p. 280 TOP: NBDHE, 6.0. Pharmacology

28. Candida albicans is a part of the normal oral flora. A decrease in occlusal vertical dimension (OVD)

will often lead to angular cheilitis. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Candida albicans can predominate when other oral flora are suppressed. Predisposing factors include moisture from drooling. Candida albicans is always present in small numbers. At one time a decrease in vertical dimension of occlusion was thought to contribute to angular cheilitis, but later evidence has shown this to not be true.

DIF: Comprehension REF: Infectious Lesions (Candidiasis (Moniliasis)) | p. 280 | Infectious Lesions (Angular Cheilitis/Cheilosis) | p. 281 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 29. Which is the most common drug associated with lichenoid-like eruptions? a. Allopurinol b. Hydrochlorothiazide (HCTZ) c. Nifedipine d. Captopril e. Procainamide ANS: B

Hydrochlorothiazide is the most commonly used thiazide diuretic. Many patients with stage 1 hypertension are treated solely with HCTZ. The most common drug implicated is hydrochlorothiazide (HCTZ). Others are -blockers and antimalarials. Nifedipine is a calcium channel blocker. Captopril is an angiotensin-converting enzyme (ACE) inhibitor. Procainamide is an antiarrhythmic.

DIF: Recall REF: Drug-Induced Oral Side Effects (Oral Lesions that Resemble Autoimmune-Type Reactions [LichenoidLike Eruptions]) | p. 285 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 30. Which is the most potent topical corticosteroid? a. Hydrocortisone b. Triamcinolone acetonide (TAC) c. Fluocinonide (Lidex) d. Clobetasol (Temovate) ANS: D

Clobetasol is used only if the other agents are ineffective. Hydrocortisone cream 1% is a low-potency topical steroid available over-the-counter (OTC). Triamcinolone acetonide (TAC) is more potent than hydrocortisone and is in the middle range of potency of the steroids. Fluocinonide (Lidex) is more potent than TAC. DIF: Comprehension REF: Agents Commonly Used to Treat Oral Lesions (Corticosteroids) | p. 287 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. The ulcerated area of ANUG begins at the marginal gingiva.

ANS: F

The ulcerated area of ANUG begins at the interdental papillae.

DIF: Recall OBJ: 1

REF: Infectious Lesions (Acute Necrotizing Ulcerative Gingivitis) | p. 278 TOP: NBDHE, 6.0. Pharmacology

2. Acyclovir should not be used prophylactically to prevent minor outbreaks of herpes because excessive

use may lead to resistant strains of herpes.

ANS: T

Excessive use of acyclovir may lead to resistant strains of herpes.

DIF: Recall OBJ: 1

REF: Infectious Lesions (Herpes Infections [Acyclovir]) | p. 280 TOP: NBDHE, 6.0. Pharmacology

3. A decrease in vertical dimension is thought to contribute to angular cheilitis.

ANS: F

In the past, a decrease in vertical dimension was thought to contribute to angular cheilitis, but recent evidence has not shown this to be true.

DIF: Recall OBJ: 1

REF: Infectious Lesions (Angular Cheilitis/Cheilosis) | p. 281 TOP: NBDHE, 6.0. Pharmacology

4. The most common drug implicated in lichenoid-like eruptions is hydrochlorothiazide.

ANS: T

Hydrochlorothiazide is the drug most commonly associated with oral lesions that resemble lichen planus. Others include -blockers and antimalarials.

DIF: Recall REF: Drug-Induced Oral Side Effects (Oral Lesions that Resemble Autoimmune-Type Reactions [LichenoidLike Eruptions]) | p. 285 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 5. The majority of cases of osteonecrosis of the jaw (ONJ) are associated with patients taking

corticosteroids.

ANS: F

Most cases of ONJ are associated with patients taking bisphosphonates.

DIF: Recall OBJ: 4

REF: Drug-Induced Oral Side Effects (Osteonecrosis of the Jaw) | p. 287 TOP: NBDHE, 6.0. Pharmacology

Chapter 26: Hygiene-Related Oral Disorders Haveles: Applied Pharmacology for the Dental Hygienist, 9th Edition MULTIPLE CHOICE 1. What percentage of adult Americans have untreated tooth decay? a. 3% b. 13% c. 23% d. 33% ANS: D

Nearly one-third of adult Americans have untreated tooth decay and one in seven adults 35 to 44 years of age have gum disease. The remaining choices do not represent the percentage of adult Americans with untreated dental caries.

DIF: Recall REF: Introduction | p. 289 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. The incidence of dental caries in children had decreased from the 1970s until the mid-1990s. This

decrease has been attributed to improved oral hygiene. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

The incidence of dental caries in children has decreased over the past decades. This decrease has been attributed to fluoridation of public water supplies, dentifrices, and mouth rinses, not improved oral hygiene. The decrease has not been attributed to improved oral hygiene. Today, the incidence of dental caries in primary teeth of children 2 to 11 years of age appears to be on the rise. Patients at highest risk for caries are those with poor oral hygiene.

DIF: Comprehension REF: Dental Caries | p. 289 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 3. The dental hygienist should teach the patient that the best way to ensure healthy teeth and gingival

tissues is to remove plaque mechanically by brushing at least twice daily and by day. a. rinsing with mouthwash b. flossing c. massaging the tissue d. using a toothpick

at least once a

ANS: B

The patient should floss at least once a day. Two methods are available to remove plaque from the teeth: mechanical and chemical methods. Mechanical methods include brushing and flossing, and chemical methods include specific drug products to prevent or remove plaque buildup. Flossing will disrupt plaque biofilm. Rinsing with mouthwash may not reach the base of the sulcus. Massaging the tissue and using a toothpick likewise will not disrupt bacteria in the sulcus.

DIF: Comprehension REF: Dental Caries (Prevention) | p. 290 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 4. Food are less cariogenic. a. with lower water content b. that stimulates saliva flow c. high in protein d. Both A and B are correct e. Both B and C are correct ANS: E

Foods that stimulate saliva flow and are high in protein are less cariogenic. Protein in dairy products raises pH levels and can inhibit bacterial growth. Foods with higher water content are less cariogenic.

DIF: Comprehension REF: Dental Caries (Prevention [Nonpharmacologic Therapies]) | p. 290 OBJ: 2 TOP: NBDHE, 6.0. Pharmacology 5. Experts recommend that the average life of a toothbrush is a. 3 b. 6 c. 12 d. 24 ANS: A

months.

Although no definite guidelines have been established as to how often patients should replace a toothbrush, experts recommend that the average life of a toothbrush is 3 months. Wear and tear and bacterial accumulation lead to increased plaque buildup instead of plaque removal. Bristles can wear and the toothbrush can become contaminated with bacteria. Most experts suggest replacing a toothbrush more frequently than the remaining choices.

DIF: Recall OBJ: 3

REF: Dental Caries (Prevention [Nonpharmacologic Therapies]) | p. 290 TOP: NBDHE, 6.0. Pharmacology

6. Which of the following statements is true concerning guidelines for the proper use of dental floss? a. The patient should pull out approximately 8 inches of floss from its container. b. Most of the floss should be wrapped around the middle fingers until approximately

1 inch of floss remains visible. c. Use a gentle gliding motion and place the floss between two teeth but do not

encroach on the gum line. d. Keep the floss taut and do not let it curve into a C-shaped curve against either tooth that forms the contact.

ANS: B

The patient should pull out the floss and wrap most of it around the middle finger. The remaining floss should be wrapped around the middle finger of the opposite hand until approximately 1 inch of floss remains visible. The patient should pull out approximately 8 inches of floss from its container. Next, use a gentle gliding motion and place the floss between two teeth until it reaches the gum line. When at the gum line, curve the floss into a C-shaped curve against one tooth and gently slide the floss into the space between the gum and tooth until the resistance is felt. Hold the floss tightly against one tooth and gently scrape the side of the tooth while moving the floss away from the gum line.

DIF: Comprehension REF: Dental Caries (Prevention [Box 26.3: Guidelines for Proper Use of Dental Floss]) | p. 291 OBJ: 3 TOP: NBDHE, 6.0. Pharmacology 7. According to the American Dental Association (ADA), which of the following groups of adults should

receive professionally applied fluoride products? a. All adults b. Only adults with active caries in the last 3 years with risk factors for caries c. Only adults with active caries in the last 3 years without risk factors for caries d. Only adults without active caries in the last 3 years without risk factors for caries e. No adults ANS: B

Only adults with active caries in the last 3 years with risk factors for caries should receive professionally applied fluoride products. Patients considered as having a moderate-to-high risk for caries benefit from professionally applied fluoride products. The type and amount of fluoride that a person receives depends on his or her risk for developing caries. Those with a low risk for caries only require fluoridated dentifrices. Additional, professionally applied fluoride is not recommended in this group because of insufficient evidence regarding any beneficial gains.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies]) | p. 291

OBJ: 4

TOP: NBDHE, 6.0. Pharmacology

8. Fluoride is thought to work by a. interacting with mineralized tissue, including bones and teeth. b. acting on individual microorganisms in biofilm. c. functioning as an antibiotic. d. doing both A and B. e. doing both B and C. ANS: D

Fluoride ions interact with mineralized tissue, including bones and teeth. Once incorporated into developing teeth, fluoride systematically reduces the solubility of dental enamel by enhancing the development of fluoridated hydroxyapatite. The second action of the fluoride ion is thought to occur on the individual microorganisms in biofilm. Topically applied stannous fluoride (SnF) inhibits bacterial enzyme systems and alters the acid production that would result in demineralization of tooth structure. Fluoride is not an antibiotic. An antibiotic is a chemical substance produced by microorganisms that have the capacity, in dilute solutions, to destroy or suppress growth or multiplication of organisms or prevent their action. An antibacterial refers to a substance from any source that inhibits or kills bacteria. An anti-infective is a substance from any source that inhibits or kills organisms that can produce infection.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies]) | p. 291 OBJ: 4 TOP: NBDHE, 6.0. Pharmacology 9. Which of the following statements is true concerning fluoride toxicity? a. Both acute and chronic toxicity can occur with fluoride use. b. Acute but not chronic toxicity can occur with fluoride use. c. Chronic but not acute toxicity can occur with fluoride use. d. Neither acute nor chronic toxicity can occur with fluoride use.

ANS: A

Both acute and chronic toxicity can occur. Acute toxicity is a result of fluoride overdose and is a medical emergency. Chronic fluoride toxicity occurs over time and is treated with medical management. The remaining choices do not correctly depict the possibilities of acute or chronic fluoride toxicity.

DIF: Application OBJ: 5

REF: Dental Caries (Prevention [Pharmacologic Therapies]) | p. 291 TOP: NBDHE, 6.0. Pharmacology

10. Which of the following liquids may be used during management of acute fluoride toxicity? a. Apple juice b. Lemonade c. Milk d. Coffee ANS: C

Immediate treatment is necessary and includes inducing vomiting and binding fluoride in the gastrointestinal tract to prevent systemic absorption. Milk will bind to fluoride and prevent systemic absorption. The other choices do not represent the liquid that may be used to bind to fluoride and prevent systemic absorption.

DIF: Recall OBJ: 5

REF: Dental Caries (Prevention [Pharmacologic Therapies]) | p. 291 TOP: NBDHE, 6.0. Pharmacology

11. Which of the following statements is true concerning chronic fluoride toxicity? a. Drinking water with more than 2 ppm of fluoride can lead to fluorosis of tooth

enamel during the age of tooth mineralization. b. Dentinal hypoplasia is the most common sign of chronic fluoride toxicity during

tooth development. c. Color changes in tooth enamel caused by chronic fluoride toxicity are a result of

hypermineralization of the outer one third of tooth enamel. d. Children that drink water with at least 0.6 ppm of fluoride and ingest fluoride supplements are at risk for developing chronic toxicity.

ANS: A

Drinking water with more than 2 ppm of fluoride can lead to fluorosis of tooth enamel during the age of tooth mineralization. Dental fluorosis or mottled tooth enamel is the most common sign of chronic fluoride toxicity during tooth development. The resultant color changes in tooth enamel caused by chronic fluoride toxicity are a result of hypomineralization of the outer one third of tooth enamel.

Children that drink water with at least 1 ppm of fluoride and ingest fluoride supplements are at risk for developing chronic toxicity.

DIF: Recall OBJ: 5

REF: Dental Caries (Prevention [Pharmacologic Therapies]) | p. 291 TOP: NBDHE, 6.0. Pharmacology

12. Which of the following types of topically applied fluoride is recommended for 4-minute topical

fluoride application when porcelain or composite restorations are present? a. Sodium fluoride (NaF) b. Acidulated phosphate fluoride (APF) c. SnF d. Both A and B e. Both B and C ANS: A

NaF is recommended when porcelain or composite restorations are present because of the damage caused by acids. The pH of APF is 3.5, which makes it acidic. Increasing the acidity of the fluoride increases the uptake of fluoride by the tooth enamel. APF is contraindicated in patients with porcelain, composite, glass ionomer restorations, or sealants. SnF is only available in a two-part rinse that contains SnF 1.64% and APF 0.3%. The manufacturer recommends a 60-second pretreatment rinse with APF to enhance stannous uptake, followed by a 60-second rinse with SnF. DIF: Recall REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 291 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology

13. Experts recommend that fluoride applications remain in place for a. 30 seconds. b. 1 minute. c. 2 minutes. d. 4 minutes.

ANS: D

Fluoride applications should remain in place for 4 minutes. Topically administered fluoride products must remain in contact with the tooth surface for a specified amount of time to allow the chemical change to develop. Some topical fluoride products are marketed as 1-minute in-office applications.

However, clinical trials have not proved that they are as effective as the 4-minute applications.

DIF: Recall REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 291 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 14. The patient is instructed to refrain from eating or drinking for

minutes after professionally

applied fluoride applications. a. 4 b. 14 c. 30 d. 60 ANS: C

The ionic exchange lasts for approximately 30 minutes after treatment with a professionally applied fluoride topical agent, which is why the patient is instructed to refrain from eating or drinking for at least 30 minutes after fluoride application. Topically administered fluoride products must remain in contact with the tooth surface for a specified amount of time to allow the chemical change to develop.

The remaining choices are not the specified amount of time.

DIF: Recall REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 291 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 15. Professionally applied fluoride topical agents last for approximately a. 5 to 8 weeks. b. 12 weeks or 3 months. c. 26 weeks or 6 months. d. 52 weeks or 1 year.

ANS: A

Professionally applied fluoride topical agents only last for approximately 5 to 8 weeks because fluoride leaches from the enamel and returns to preapplication levels. Daily applications of low concentrationfluoride dentifrices help maintain fluoride levels in tooth structure. The other choices do not express the time frame for the benefit of professionally applied topical fluoride agents.

DIF: Recall REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 291 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology

16. Annual 4-minute in-office topical fluoride applications reduce tooth decay in permanent teeth of

children living in nonfluoridated areas by a. 6%. b. 16%. c. 26%. d. 36%.

ANS: C

Decay is reduced by 26% in permanent teeth of children living in nonfluoridated areas when 4-minute in-office topical fluoride applications are applied annually. The remaining choices are not the correct percentage for the reduction in caries in the permanent teeth of children in nonfluoridated areas that can be expected when annual 4-minute in-office topical fluoride applications are utilized.

DIF: Recall REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 291 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 17. Some topical fluoride products are marketed as 1-minute in-office applications. Clinical trials have

proved that they are as effective as the 4-minute applications. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Some topical fluoride products are marketed as 1-minute in-office applications. However, clinical trials have not proved that they are as effective as the 4-minute applications. The ADA has given its Seal of Acceptance only to the 4-minute application products.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 291 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 18. Which of the following professionally applied preparations for in-office application has the highest

fluoride concentration (ppm)? a. Sodium 2% b. Sodium varnish 5% c. APF 1.23% d. 0.4% SnF and 1.1% NaF in APF ANS: B

Sodium varnish 5% has a fluoride concentration of 22,600 ppm. Solution, foam, gels, and varnish for in-office applications include sodium 2%, which has a fluoride concentration of 9050 ppm, and APF 1.23%, which has a fluoride concentration of 1.23%. Prescription gels for daily home use such as 0.4% SnF and 1.1% NaF in APF have a fluoride concentration of 5000 ppm.

DIF: Recall REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Agents] [Table 26.2: Fluoride Concentrations of Professionally Applied Preparations]) | p. 292 OBJ: 6 TOP: NBDHE, 6.0. Pharmacology

19. Which of the following statements is true of professionally applied NaF varnish? a. NaF varnish is available in Europe but is not currently available in the United

States as a dentin-desensitizing agent and as a cavity liner. b. The US Food and Drug Administration (FDA) has approved the varnish for its anticaries effect. c. The use of fluoride varnish for caries prevention has been endorsed by the ADA. d. NaF varnish is available as a 5% solution.

ANS: C

Use of fluoride varnish for caries prevention has been endorsed by the ADA. It is the recommended method of fluoride application for those at high risk for caries. NaF varnish with a 5% sodium fluoride concentration is currently available for use in the United States as a dentin-desensitizing agent and as a cavity liner. The FDA has not approved the varnish for its anticaries effect.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 292 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 20. Which of the following statements is true of NaF varnish as a professionally applied topical agent? a. The varnish requires prior oral prophylaxis. b. The varnish stays on the enamel longer than topical fluoride. c. The varnish can be applied if saliva is present. d. Both A and B are true. e. Both B and C are true.

ANS: E

The varnish stays on the enamel longer than topical fluorides and can be applied if saliva is present. It dries quickly and is slowly released into saliva, therefore less systemic absorption occurs, which reduces the risk of toxicity. The varnish can be applied without prior oral prophylaxis.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 292 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 21. The patient should not eat for

for a. b. c. d. e.

after the application of NaF varnish and should not brush his teeth

.

30 minutes; 30 minutes 30 minutes; 60 minutes 1 hour; 2 hours 2 hours; 1 day 2 hours; 2 days

ANS: D

The patient should not eat for 2 hours after the application of NaF varnish and should not brush his teeth for 1 day after the varnish has been applied. Toothbrushing can remove the newly applied varnish. There are specific recommendations regarding the time frame for eating and brushing teeth following the application of NaF varnish. The other choices do not correctly reflect these times.

DIF: Recall

REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Gels]) | p. 292 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 22. Which of the following statements is true regarding use of dentifrices in the United States? a. Nearly 75% of all dentifrices or toothpastes available in the United States contain

some form of fluoride, but the remaining 25% of these products do not. b. Some products contain triclosan 0.3%, as well as fluoride, but these products do

not carry ADA approval for claimed effects against gingivitis. c. Studies have shown that children between the ages of 10 and 15 years who brush three times daily with a fluoride dentifrice showed no reduction in the decayedmissing-filled rate compared with those that only brush once a day. d. Children should use a pea-sized amount of toothpaste to minimize fluoride ingestion.

ANS: D

Children should use a pea-sized amount of toothpaste to minimize fluoride ingestion. Nearly 98% of all dentifrices or toothpastes available in the United States contain some form of fluoride. Products that contain triclosan 0.3% carry ADA approval for its effects against gingivitis. Studies have shown that children between the ages of 10 and 15 years who brush three times daily with a fluoride dentifrice have a 46% reduction in the decayed-missing-filled rate compared with those who only brush once a day (21%).

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Patient-Applied Topical Fluoride Preparations]) | p. 294 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 23. Which of the following agents is added to mouth rinses to function as a foaming agent that helps

remove debris? a. Alcohol b. Surfactants c. Glycerin d. Benzoic acid ANS: B

Surfactants are foaming agents that help remove debris. Cosmetic mouth rinses freshen the breath and remove debris. Alcohol is added to mouth rinses to provide bite and freshness and to enhance flavor, solubilize other ingredients, and contribute to the mouth rinse’s cleansing action and antibacterial activity. Glycerin tastes sweet and is soothing to the oral mucosa. Benzoic acid is an antimicrobial agent.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Patient-Applied Topical Fluoride Preparations]) | p. 294 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 24. Guidelines for using at-home topical fluoride preparations include a. topical fluoride rinses should be used no more than four times per day. b. brush teeth with a fluoride dentifrice after rinsing with the at-home topical fluoride

preparation. c. swallow the fluoride rinse for a systemic effect.

d. rinse vigorously for approximately 60 seconds.

ANS: D

Guidelines for using at-home topical fluoride preparations include vigorously rinsing for approximately 60 seconds. Topical fluoride rinses should be used no more than once per day. Brush teeth with a fluoride dentifrice before rinsing. Spit out the fluoride rinse. Do not swallow the rinse.

DIF: Recall REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Patient-Applied Topical Fluoride Preparations] [Box 26.5: Guidelines for Using At-Home Topical Fluoride Preparations]) | p. 295 OBJ: 8 TOP: NBDHE, 6.0. Pharmacology 25. Which of the following statements is true of Xylitol? a. Xylitol has been found to reduce the levels of Streptococcus mutans in saliva but b. c. d. e.

not plaque.

Xylitol has been found to inhibit the attachment of biofilm to teeth.

Xylitol can prevent the transmission of oral bacteria from mother to child.

Both A and B are true.

Both B and C are true.

ANS: E

Xylitol has been found to inhibit the attachment of biofilm to teeth, and it can prevent the transmission of oral bacteria from mother to child. Xylitol has been found to reduce the levels of S. mutans in saliva and plaque. It interferes with the metabolism of S. mutans as it is transported into the cell. Once in the cell, it may stay bound to the transport protein.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Xylitol]) | pp. 294-295 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology 26. Which of the following statements is true of the use of chlorhexidine rinse for the treatment of

gingivitis? a. Chlorhexidine is active against gram-positive but not gram-negative bacteria. b. Chlorhexidine is subject to bacterial resistance. c. Chlorhexidine binds to the bacterial cell membrane and increases its permeability. d. Chlorhexidine is used prophylactically.

ANS: C

Chlorhexidine binds to the bacterial cell membrane and increases its permeability, which results in cell death. Chlorhexidine is active against both gram-positive and gram-negative bacteria and has some antifungal activity. It is a safe product that does not appear to succumb to bacterial resistance.

Chlorhexidine rinse is used in persons with periodontal disease. It is not used prophylactically but as an adjunct therapy for up to 6 months.

DIF: Comprehension REF: Gingivitis (Prevention [Chlorhexidine]) | p. 295 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 27. Patients should rinse with chlorhexidine for 30 seconds with 15 ml of chlorhexidine a. once b. twice

a day.

c. three times d. four times ANS: B

Patients should rinse with chlorhexidine for 30 seconds with 15 ml of chlorhexidine twice a day. The most common adverse effects include tooth and mucosal staining, bitter taste, taste alteration, increased calculus formation, and mucosal irritation. Chlorhexidine is a prescription medication. The manufacturer’s instructions are specific regarding the frequency of use of chlorhexidine. The remaining choices are not correct regarding the recommended frequency of use.

DIF: Recall OBJ: 9

REF: Gingivitis (Prevention [Chlorhexidine]) | p. 295 TOP: NBDHE, 6.0. Pharmacology

28. In a recent clinical trial, an essential oil mouth rinse plus brushing and flossing was a. not found to be effective in reducing interproximal bleeding. b. found to be effective in reducing interproximal pocket depths. c. found to produce similar results to chlorhexidine at the end of 3 months of therapy. d. found to produce similar results to chlorhexidine at the end of 6 months of therapy.

ANS: D

When compared with chlorhexidine, the essential oil mouth rinse produced similar results to chlorhexidine at the end of 6 months of therapy. Chlorhexidine showed improvement at the end of the first 3 months. In a recent clinical trial, an essential oil mouth rinse plus brushing and flossing was found to be effective in reducing interproximal bleeding but not interproximal pocket depths.

DIF: Comprehension REF: Gingivitis (Prevention [Essential Oils]) | p. 296 OBJ: 10 TOP: NBDHE, 6.0. Pharmacology 29. Which of the following treatments is the most effective in reducing gingivitis? a. Sodium 2% fluoride b. APF 1.23% c. 0.4% SnF and 1.1% NaF in APF d. 0.3% triclosan ANS: D

Research has shown that triclosan is more effective than fluoridated products in reducing gingivitis.

Triclosan is a natural substance that has antibacterial efficacy that reduces plaque and gingivitis.

Triclosan carries the ADA Seal of Acceptance as an antigingivitis agent. More recently, the FDA has stated that there is no evidence that triclosan in personal care items provides any additional benefits beyond its antigingivitis effects found in toothpaste. One of these items has been shown by research to be more effective in reducing gingivitis than the rest.

DIF: Recall OBJ: 10

REF: Gingivitis (Prevention [Triclosan]) | p. 296 TOP: NBDHE, 6.0. Pharmacology

30. For dentinal hyperalgesia (DH) to develop, the dentin must become exposed through the loss of

gingival recession or enamel, and a. the dentin tubules must be open to the oral cavity and the pulp. b. the tooth must be in hyperocclusion. c. erosion at the cervical must be present.

d. a carious exposure of the tooth pulp must be present.

ANS: A

For DH to develop, the dentin must become exposed through the loss of gingival recession or enamel, and the dentin tubules must be open to the oral cavity and the pulp. This occurs when the smear layer of the dentin tubular plugs is removed and the outer orifice of the tubule is opened and exposed to stimuli. The remaining choices do not represent the criteria necessary for dentinal hyperalgesia to develop.

DIF: Recall OBJ: 11

REF: Tooth Hypersensitivity (Pathophysiology) | p. 296 TOP: NBDHE, 6.0. Pharmacology

31. Which of the following choices is the most common cause of intrinsic acid production? a. Medication b. Gastric reflux c. Wine d. Ciders ANS: B

The most common cause of intrinsic acid production is gastric reflux. Dental erosion is a result of both intrinsic and extrinsic acid. Extrinsic sources of acid include medication, foods, and drink. Citrus juices, carbonated drinks, wines, and ciders put the patient at risk for tooth hypersensitivity.

DIF: Recall OBJ: 10

REF: Tooth Hypersensitivity (Pathophysiology) | p. 296 TOP: NBDHE, 6.0. Pharmacology

32. The majority of desensitizing toothpastes contain a. NaF. b. oxalates. c. adhesives and resins. d. 5% potassium nitrate.

ANS: D

The majority of desensitizing toothpastes contain 5% potassium nitrate. Professionally applied products include fluorides (NaF, SnF), potassium oxalate, and adhesives and resins. Their effects are temporary because they do not adhere to the dentin surface.

DIF: Recall OBJ: 11

REF: Tooth Hypersensitivity (Treatment [At-Home Therapies]) | p. 296 TOP: NBDHE, 6.0. Pharmacology

33. Almost which percentage of Americans 60 years and older have lost all their teeth? a. 5 b. 10 c. 15 d. 20 e. 25 ANS: E

This is actually an improvement from the past. The growing number of older persons with their own natural teeth has many dental implications. Almost 25%. Less than 60% of adults older than 65 years visit an oral health care provider during a given year.

DIF: Recall REF: Introduction | p. 289 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

34. Professionally applied NaF varnish is available with a sodium fluoride concentration of a. 1.23%. b. 1.64%. c. 2%. d. 5%.

ANS: D

NaF varnish with a 5% sodium fluoride concentration is currently available for use in the United States as a dentin-desensitizing agent and as a cavity liner. APF is available in a 1.23% concentration. SnF is available in a two part rinse that contains SnF 1.64% and APF 0.3%. Topical NaF is available as a viscous gel or foam and is stable in a 2% solution.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Agents]) | p. 292 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 35. Topical NaF 2% is recommended for patients with porcelain or composite restorations. APF 1.23% is

not recommended for patients with porcelain or composite restorations. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second is false. d. The first statement is false, the second is true.

ANS: C

Neutral sodium fluoride (NaF) will not etch porcelain or composite restorations and is recommended when these restorations are present. Acidulated phosphate fluoride (APF) will etch porcelain or composite restorations. All NaF agents have a neutral pH of 7.0 and are ideal for porcelain or composite restorations. The pH of APF 1.23% is 3.5. APF is contraindicated in patients with porcelain or composite restorations.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride Preparations] [Professionally Applied Fluoride Topical Agents]) | p. 293 OBJ: 7 TOP: NBDHE, 6.0. Pharmacology 36. Each of the following is true of xylitol EXCEPT one. Which is the EXCEPTION? a. It looks and tastes like glucose. b. It will reduce the levels of Streptococcus mutans in plaque and saliva. c. It will inhibit the attachment of biofilm to teeth. d. It will prevent the transmission of oral bacteria from mother to child.

ANS: A

Xylitol is a natural product that looks and tastes like sucrose, rather than glucose. Xylitol will reduce the levels of Streptococcus mutans, it will inhibit the attachment of biofilm to teeth, and it will prevent the transmission of oral bacteria from mother to child. The degree of antibacterial effect depends on the amount of xylitol ingested and the frequency of use.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Patient-Applied Topical Fluoride Preparations] [Xylitol]) | p. 294 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology 37. Which is a bisbiguanide local antiinfective available in a 0.2% mouthrinse? a. Xylitol b. Chlorhexidine gluconate c. Essential oil d. Triclosan ANS: B

It is used to kill Streptococcus mutans bacteria and reduce the harmful effects of biofilm. Xylitol is a natural product found in plants. Essential oil mouth rinses contain thymol, menthol, and eucalyptol.

Triclosan is a natural substance with antibacterial efficacy that reduces plaque and gingivitis.

DIF: Comprehension REF: Dental Caries (Prevention [Pharmacologic Therapies] [Patient-Applied Topical Fluoride Preparations] [Chlorhexidine]) | p. 295 OBJ: 9 TOP: NBDHE, 6.0. Pharmacology 38. The FDA has stated that triclosan is effective against a. occlusal caries. b. proximal caries. c. gingivitis. d. periodontitis.

ANS: C

Triclosan does not have any side effects and is safe to use. The FDA has stated that there is no evidence that triclosan in personal care items provides any additional benefits beyond the antigingivitis effects found in toothpaste.

DIF: Recall OBJ: 10

REF: Gingivitis (Prevention [Triclosan]) | p. 296 TOP: NBDHE, 6.0. Pharmacology

39. Which in-office therapy for tooth hypersensitivity lasts longest? a. NaF b. SnF c. Oxalate d. Adhesive products ANS: D

Adhesive products provide longer-lasting desensitization. They include cavity varnishes, bonding agents, and restorative resin materials. NaF is thought to work through the formation of insoluble calcium fluoride within the dentinal tubules. SnF is applied as a paste or solution and burnished over the sensitive area. Oxalate products reduce dentin permeability and occlude the dentinal tubules.

DIF: Comprehension REF: Tooth Hypersensitivity (Treatment [In-Office Therapies]) | p. 297 OBJ: 11 TOP: NBDHE, 6.0. Pharmacology TRUE/FALSE 1. Dental disorders result in 7 million days of lost work each year.

ANS: T

Oral disorders or diseases are among the most prevalent diseases in American society.

DIF: Recall REF: Introduction | p. 289 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

2. Approximately 40% of the general population has experienced dental caries.

ANS: F

Approximately 20% of the general population has experienced dental caries. The incidence of dental caries in children has decreased over the past decade.

DIF: Recall REF: Dental Caries | p. 289 TOP: NBDHE, 6.0. Pharmacology

OBJ: 1

3. Proteins in dairy products raise pH levels and can inhibit bacterial growth.

ANS: T

Foods with higher water content, those that stimulate saliva flow, and foods high in protein are less cariogenic.

DIF: Recall REF: Dental Caries (Prevention [Nonpharmacologic Therapies] [Dietary Measures]) | p. 290 OBJ: 1 TOP: NBDHE, 6.0. Pharmacology 4. Patients considered as having a low risk for caries benefit from professionally applied fluoride

products.

ANS: F

Patients considered as having a moderate-to-high risk for caries benefit from professionally applied fluoride products. Those with a low risk for caries require fluoridated dentifrices only. Additional, professionally applied fluoride is not recommended in this group because of insufficient evidence regarding any beneficial gains.

DIF: Recall OBJ: 4

REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride]) | p. 291 TOP: NBDHE, 6.0. Pharmacology

5. Children that drink water with at least 1 ppm of fluoride and ingest fluoride supplements are at risk for

developing chronic fluoride toxicity.

ANS: T

The treatment of chronic toxicity is one of esthetics and includes bleaching the anterior teeth and covering the anterior teeth with porcelain restorations.

DIF: Recall REF: Dental Caries (Prevention [Pharmacologic Therapies] [Fluoride] [Chronic Toxicity]) | p. 291 OBJ: 5 TOP: NBDHE, 6.0. Pharmacology 6. Tooth bleaching can increase the risk for sensitivity.

ANS: T

Tooth hypersensitivity can occur after teeth whitening treatments when the root surfaces are exposed.

DIF: Recall REF: Tooth Hypersensitivity | p. 296 TOP: NBDHE, 6.0. Pharmacology

OBJ: 11