1 What is the mechanism of action of Clindamycin?

Inhibit bacterial protein synthesis

Concept
Clindamycin is a 50S ribosomal subunit inhibitor whose antibacterial properties stem from
inhibition of protein synthesis. It is commonly used to treat a variety of infections including
respiratory, dermatologic, intra-abdominal, and dental infe

2. Each of the following drugs are most likely to cause gingival hyperplasia EXCEPT one. Which
is the EXCEPTION?
A. Phenytoin (Phenytek®) [3%]
B. Cyclosporine (Neoral®) [8%]
C. Nifedipine (Procardia XL®) [4%]
D. Bisoprolol (Concor®) [85%]
For the INBDE, it is important to know that drug-induced gingival hyperplasia is associated with
3 types of drugs:
1. Immunosuppressants, such as Cyclosporines (Neoral®)
2. Anticonvulsants, such as Phenytoin (Phenytek®)
3. Calcium channel blockers, such as Nifedipine (Procardia XL®), Diltiazem (Tiazac®), Verapamil
(Verelan®)

Candidiasis, commonly caused by the fungus Candida albicans, presents as white plaques on
the hard palate and tongue in denture wearers, as shown in the image below. Candida
infections are more prevalent in immunosuppressed individuals or on some
immunosuppressant therapy. Patients with rheumatoid arthritis may be taking an
immunosuppressive medication to help alleviate the symptoms associated with the disease,
such as adalimumab (Humira®). This immunosuppression can lead to candidiasis.
Which is the most likely cause of the chief complaint?
A. Medication-related osteonecrosis [91%]
B. Allergic reaction [0%]
C. Residual root tip [8%]
D. Bacterial endocarditis [1%]

Medication–related osteonecrosis of the jaw (MRONJ) is the most likely cause for post-
extraction pain and exfoliation of necrotic bone, based on the patient’s background and clinical
findings. There is a strong association between IV bisphosphonate use, such as pamidronate
(Aredia®), and risk for MRONJ. IV bisphosphonates are commonly used to control blood
calcium levels in patients with significant bone resorption, such as those with osteoporosis or
bone-related cancers. The image below shows a clinical example of MRONJ.

5. Each of the following medications has anti-inflammatory properties EXCEPT one. Which is
the EXCEPTION?
A. Montelukast (Singulair®)
B. Ibuprofen (Advil®)
C. Aspirin (Disprin®)
D. Celecoxib (Celebrex®)
E. Perindopril (Aceon®)
Non-steroidal anti-inflammatory drugs (NSAIDs) provide anti-inflammatory benefits. The
mechanism at which NSAIDs act is shown in the image below. This drug category includes
many over-the-counter analgesics, including the following:

1. Ibuprofen (Advil®)
2. Aspirin (Disprin®)
3. Celecoxib (Celebrex®) is a prescription NSAID

6. Which is the most likely oral side effect of antipsychotic medications?

A. Xerostomia [94%]
B. Aphthous ulcers [2%]
C. Candidiasis [2%]
D. Hypercalcification [2%]

Antipsychotics are a type of psychiatric medication which are available on prescription to treat
psychosis. Due to their mechanisms of action, a common side effect is xerostomia (dry mouth)
caused by decreased stimulation of the salivary glands. The image below shows decreased or
insufficient functioning of salivary glands that led to xerostomia.
 Warfarin (Coumadin®) is an anti-coagulant medication that is used for prevention of clot
formation. International normalized ratio (INR) describes how thick or thin an individual’s
blood is and is calculated based on the results of an individual’s prothrombin time. An INR
value between 0.9 to 1.1 is considered normal and indicates that the blood clots within a
normal time. A lower INR value indicates thicker blood and a faster clotting time, whereas a
higher INR value indicates thinner blood and a longer clotting time. The therapeutic INR range
for an individual taking warfarin (Coumadin®) is between 2.0 to 3.0, as shown in the image
below.

Clopidogrel (Plavix®) is an anti-platelet medication that prevents platelet aggregation by

inhibiting binding of ADP to the P2Y12 receptor. Platelet levels should be >50,000/mm3 before
performing invasive dental procedures.

Hypercholesterolemia is an elevated level of LDL-cholesterol (i.e. “bad” cholesterol) in the

blood. Pharmacological therapy is often best accomplished by using drugs from the “statin”
class. HMG-CoA reductase is an important enzyme involved in the hepatic synthesis of
cholesterol. As shown in the flow chart illustrating cholesterol synthesis below, statins are
reversible competitive inhibitors of HMG CoA reductase, and they have a much higher affinity
for this enzyme than HMG CoA. As a result, intracellular cholesterol synthesis is inhibited via
the liver.

Epileptogenesis is the process where the normal brain is biased towards the generation of
abnormal electrical activity in the brain, leading to seizures. This is due to imbalances such as
increased excitation, decreased inhibition, changes in ion channels and alteration of ionic
concentration. Different medications affect different parts of these imbalances in an attempt
to control the seizure.

Carbamazepine aims to control the increased excitation, by blocking voltage-dependent

sodium channels that are firing at high frequencies, as shown in the image below.
10. Which drug is indicated in the immediate management of a suspected opioid overdose?
A. Meperidine (Demerol®) [1%]
B. Flumazenil (Romazicon®) [5%]
C. Epinephrine (Epipen®) [2%]
D. Naloxone (Narcan®) [92%]

Naloxone (Narcan®) is used to reverse the drug effects of opioid overdose by acting as a non-
selective and competitive opioid receptor antagonist. The effects of naloxone begin within 2
minutes when given intravenously, and 5 minutes when given intramuscularly. It is important
to remember that multiple doses of naloxone may be required, as the duration of the effect of
the opioid is often greater than that of naloxone.

11. Which class of drugs is most appropriate for oral sedation in an anxious adult patient?
A. Calcium channel blockers [0%]
B. Barbiturates [3%]
C. Benzodiazepines [96%]
D. Opioids [1%]
Benzodiazepines are among the most used drugs for conscious sedation due to their anxiolytic,
hypnotic and sedative properties. They have a large margin of safety, good efficacy, are well
absorbed and have a relatively rapid onset. The mechanism of action of benzodiazepine
involves increasing the effectiveness of the neurotransmitter GABA, to decrease the
excitability of neurons. This is depicted below.

Below are various forms of oral benzodiazepines you should be familiar with:

• Midazolam (0.25 – 0.5 mg/kg) – Taken 30 min preoperatively for pediatric patients or
developmentally delayed adults. Half-life is 1-4h.
• Lorazepam (0.5 – 2 mg) – May be given either by the sublingual or oral route. Half-life is 12-
18h.
• Diazepam (5 – 10 mg po) – May be given with sips of water ½ – 1 hr preoperatively. Half-life
is 20-80h.
Carbamazepine is an anticonvulsant medication that can be used to treat the following:

– Neuropathic pain, such as trigeminal neuralgia and diabetic neuropathy

– Schizophrenia
– Generalized seizures

However, it is NOT an approved treatment for generalized anxiety.

Nifedipine is a commonly prescribed medication for hypertension; and is the prime suspect
here for the resulting gingival hyperplasia. It is a calcium channel blocker, which is a class of
antihypertensive drugs known to have gingival hyperplasia as an adverse effect. Other drugs
that are known to contribute to gingival hyperplasia are phenytoin, sodium valproate,
cyclosporine, diltiazem and verapamil.

14. What is the mechanism of action of sertraline (Zoloft®)?

A. It blocks the reuptake of serotonin and norepinephrine [28%]
B. It increases the levels of norepinephrine, serotonin and dopamine, by inhibiting their
degradation [9%]
C. It binds to a specific site associated with the GABA receptor, which results in increased
inhibition [5%]
D. It blocks the reuptake of serotonin [58%]

Sertraline (Zoloft®) belongs to a class of antidepressants known as Selective Serotonin

Reuptake Inhibitors (SSRIs).

15. What is the mechanism of action of penicillin?

A. Inhibits the synthesis of bacterial cell wall [90%]
B. Causes protein synthesis inhibition through reversible binding to bacterial 30 S ribosomal
subunits [3%]
C. Acts by inhibiting DNA synthesis through a specific action on DNA gyrase [2%]
D. Binds with ergosterol of bacterial cell membrane, forming pores that cause leakage of
contents and subsequent cell death [5%]

16. What is the mechanism of action of fluoxetine (Prozac®)?

A. Inhibits serotonin reuptake by central nervous system neurons [63%]
B. Increases norepinephrine and serotonin levels by inhibiting their metabolism [27%]
C. Antagonizes central presynaptic α2 receptors [5%]
D. Interferes with the binding of angiotensin II with its receptor [5%]
Phenytoin (Dilantin®) is an antiseizure medication that is used to control, treat and prevent
tonic-clonic and focal seizures. In addition to headache, nausea and vomiting, phenytoin may
also cause gingival overgrowth.

19. What is the mechanism of action of omeprazole?

A. Acid reducer [5%]
B. Proton pump inhibitor [90%]
C. Angiotensin-converting inhibitor enzyme [3%]
D. Histamine-2 blocker [2%]

Omeprazole is an proton-pump inhibitor (PPI) and is commonly used treatment for acid reflux.
It works to suppress the stomach acid secretions by inhibiting H+/K+-ATPase in the gut, as
shown in the image below. In other words, it binds to the acid-producing pumps in the gut and
turns them off, resulting in decreased acid production. PPI names typically end in “azole.”
20. What is the mechanism of action of rivaroxaban (Xarelto®)?
A. Irreversibly inactivates cyclooxygenase (COX)-1 [7%]
B. Inhibits the synthesis of Vitamin K [7%]
C. Irreversibly binds to P2Y12 class of ADP receptors on platelets [11%]
D. Factor Xa inhibitor

Rivaroxaban (Xarelto®) is a commonly used anticoagulant. It is used to treat and prevent blood
clots, reduces the risk of strokes, deep vein thrombosis and pulmonary embolisms.
Rivaroxaban should not be combined with any other medications that may increase the risk of
bleeding including NSAIDs, aspirin, heparin, or selective serotonin reuptake inhibitors (SSRIs).
Rivaroxaban works as a factor Xa inhibitor, as shown in the image below

Hypersensitivity is any immune response to a foreign antigen that is exaggerated beyond the
norm. Below are the four types of hypersensitivity that you should know for the INBDE.

Type 1 Hypersensitivity (immediate) – seen in anaphylaxis and food allergies

Type 2 Hypersensitivity (cytotoxic) – seen in the destruction of red blood cells by activated
complement

Type 3 Hypersensitivity (immune complex-mediated) – seen in glomerulonephritis and

rheumatoid arthritis

Type 4 Hypersensitivity (delayed or cell-mediated) – seen in delayed responses such as contact

dermatitis and tuberculin reactions
Type 2 diabetes mellitus is characterized by increased insulin resistance and progressive
pancreatic beta cell failure. Metformin (Glucophage®) is one of the most common medications
prescribed to type II diabetes mellitus patients. At the physiological level, metformin
(Glucophage®) has been shown to reduce blood glucose levels by inhibiting hepatic glucose
production. At the molecular level, its mechanism of action is to decrease glucagon levels by
binding to adenosine monophosphate (AMP) protein kinase receptors and suppress hepatic
gluconeogenesis, as shown in the image below.
25. Which is true regarding warfarin (Coumadin®)?
A. It is a Vitamin K agonist [19%]
B. Requires strict PT and PTT monitoring for patients [8%]
C. Contraindicated for use in patients with history of pulmonary embolism [2%]
D. Affects coagulation factors II, VII, IX, X [71%

Warfarin (Coumadin®) is a common anticoagulant medication used in preventing blood clots. It

blocks the Vitamin K epoxide reductase enzyme, which works to reduces Vitamin K, thereby
reactivating it. Vitamin K is necessary for the synthesis of clotting factors II, VII, IX and X. These
factors are part of the clotting cascade. Below is a picture of the clotting cascade and the
clotting factors affected by Warfarin, as well as other common anticoagulant medications.

26. What is the FDA cleared use of silver diamine fluoride (SDF)?
A. Desensitization [45%]
B. Salivary stimulation [1%]
C. Caries arrest [46%]
D. Caries prevention [8%]

Silver diamine fluoride (SDF) is a topical medication used to treat and prevent dental caries
(tooth decay) and relieve dentinal hypersensitivity. Although it has many off-label uses and
advantages, the only FDA-cleared use is its use as a dentinal desensitizing agent. The silver and
fluoride components in SDF have been shown to create a layer in covering exposed dentin and
plugging dentin tubules to provide symptom relief. The image below highlights the
advantages/disadvantages of SDF.
27. Which is true regarding the mechanism of action of bisphosphonates?
A. Bisphosphonates disrupt osteoclast function [90%]
B. Bisphosphonates disrupt osteoblast function [7%]
C. Bisphosphonates disrupt calcium absorption [2%]
D. Bisphosphonates disrupt calcium deposition [1%]

Bisphosphonates are commonly used in the treatment of osteoporosis, Paget disease, multiple
myeloma, hypercalcemia of malignancy and malignant metastasis to bone. It acts by disrupting
and inhibiting osteoclast activity (cells that degrade bone to initiate normal bone remodeling
by increasing their resorptive activity). The two classes of bisphosphonates include nitrogen
containing and non-nitrogen containing compounds, both of which affect osteoclast activity as
shown in the image below. The decrease in osteoclast activity disrupts bone remodeling and is
used therapeutically with the aim of slowing bone loss.

28. What is the mechanism of action of argatroban?

A. Factor Xa inhibitor [31%]
B. Xa & thrombin Inhibitor [11%]
C. Vitamin K antagonist [5%]
D. Direct thrombin Inhibitory [53%]

Argatroban is an anticoagulant, also known as a blood thinner, which reduces the coagulation
of blood. Anticoagulants can be divided into four groups:

1. Factor Xa inhibitors
2. Low molecular weight heparins
3. Direct thrombin inhibitors
4. Vitamin K antagonists
32. Which statement is correct regarding the mechanism of action of sulfonylureas?
A. Act on ATP-sensitive potassium channels located on the cell membrane of pancreatic beta
cells. [56%]
B. Act on ATP-sensitive calcium channels located on the cell membrane of pancreatic beta
cells. [33%]
C. Act on ATP-sensitive potassium channels located on the cell membrane of pancreatic alpha
cells. [8%]
D. Act on ATP-sensitive calcium channels located on the cell membrane of pancreatic alpha
cells. [3%]

Sulfonylureas is a class of medications used to treat type 2 diabetes. Sulfonylureas will act on
and close ATP-sensitive potassium channels on the cell membrane of pancreatic beta cells
initiating the release of insulin. Diet and exercise are used in conjunction with sulfonylureas to
control blood sugar. Some common types of sulfonylureas used in the treatment of Type 2
diabetes are glipizide, glimepiride, and glyburide.
33. What primary ingredient in Hemodent® is responsible for its hemostatic properties?
A. Fe2(SO4 )3 (Ferric Sulfate) [40%]
B. AlCl3 (Aluminum Chloride) [44%]
C. AgNO3 (Silver Nitrate) [6%]
D. C8H15NO2 (Tranexamic Acid) [10%]

Hemodent® is a topical hemostatic agent that effectively stops minor gingival bleeding, as
shown in the image below. It is composed of a buffered aluminum chloride solution with acidic
properties that constrict blood vessels and stimulate formation of coagulated proteins, thus
creating a barrier in small blood vessels. Hemodent® is a chemical hemostatic liquid used to
arrest bleeding during several procedures including crown preparations, impressions, and
fillings.

Sialorrhea is drooling or excessive salivation that can be caused by

– Dental malocclusion
– Gastroesophageal reflux
– Neurologic disease such as Cerebral Palsy, Parkinson’s disease, or Strokes
– Medications such as cholinomimetics or antipsychotics (note – this patient is taking clozapine
for schizophrenia)

35. What is the mechanism of action of bupropion (Wellbutrin®)?

A. Inhibit reuptake of serotonin at the synapse [13%]
B. Inhibit reuptake of serotonin and norepinephrine at the synapse [27%]
C. Inhibit norepinephrine and dopamine reuptake at the synapse [44%]
D. Inhibit dopamine reuptake at the synapse [16%]

Bupropion is an atypical antidepressant that inhibits norepinephrine and dopamine reuptake

at the synapse. It is also used for smoking cessation and has a favorable sexual side effect
profile as compared to selective serotonin reuptake inhibitors (SSRIs).
Which is a function of IgA in saliva?
A. Present bacterial antigens to the immune system
B. Prevent binding and absorption of foreign bacteria
C. Perforate foreign bacteria
D. Activate phagocytic system

Angiotensin converting enzyme (ACE) is an enzyme that converts angiotensin I to angiotensin

II, an intermediary which is then converted into aldosterone, as pictured below.

What is the mechanism of action of adalimumab?

A. Modulate the activity of GABA neurotransmitter [5%]
B. Inhibition of Na+/K+ ATPase [10%]
C. Inhibits the acetylcholinesterase activity [5%]
D. Inhibits the binding of TNF alpha to its receptor [80%]
4. Each of the following is an oral antidiabetic agent EXCEPT one. Which is the EXCEPTION?
A. Miglitol (Glyset®) [16%]
B. Semaglutide (Rybelsus®) [11%]
C. Meclizine (Bonine®) [53%]
D. Pioglitazone (Actos®) [

6. Each of the following is an oral side effect of chemotherapy EXCEPT one. What is the
EXCPETION?
A. Dry mouth [1%]
B. Infection [9%]
C. Oral mucositis [2%]
D. Teeth discoloration [88%]

7. Each of the following is correct regarding codeine EXCEPT one. Which is the EXCEPTION?
A. It can cause constipation [5%]
B. It binds to mu-opioid receptors [4%]
C. It is safe to use during the third trimester of pregnancy [88%]
D. It can cause CNS depression and addiction [3%]

Codeine is an opioid prescribed as a pain reliever to treat mild to severe pain. It is available and
can be prescribed as a single-ingredient medication or in combination with acetaminophen,
aspirin, or medications for cold and cough. However, it is contraindicated during pregnancy
due to adverse effects to the newborn such as premature birth, low birth weight, hypoxic-
ischemic brain injury, and death
5. The dentist prescribes the patient a denture adhesive to be used temporarily till new
dentures are made. Two weeks later, the patient calls up complaining of vomiting, diarrhea,
and some numbness in the extremities. He mentioned it all started after using the denture
adhesive. What could have led to these symptoms?
A. Carboxymethylcellulose [9%]
B. Polymethyl vinyl ether [15%]
C. Zinc [73%]
D. Selenium [3%]
8. What is the mechanism of action of lacidipine?
A. Diuretic [7%]
B. Reversible inhibition of COX 1 and 2 [2%]
C. Selective serotonin reuptake inhibitor [9%]
D. Calcium channel blocker [82%]

Lacidipine is an effective oral antihypertensive medication classified as a calcium antagonist

with a selectivity for calcium channels in the vascular smooth muscle. The muscle contraction
is initiated by the inflow of calcium; lacidipine, as a calcium channel blocker, inhibits its entry
into cells, as shown in the image below. This causes the vascular and arterial smooth muscle
cells to relax resulting in vasodilation.
Angiotensin-converting enzyme (ACE) inhibitors are drugs that help decrease high blood
pressure. They work by preventing enzymes in the body from making angiotensin II which is a
substance that constricts blood vessels. Since there is less angiotensin II being made when ACE
inhibitors are used, blood vessels dilate causing blood pressure to decrease. Common side
effects of ACE inhibitors include increases potassium levels, fatigue, and an unproductive
cough. The drug Lisinopril (Zestril®) is an ACE inhibitor.

10. An acute asthma attack involves the release of which mediator?

A. Prostaglandin [7%]
B. Histamine [81%]
C. Bradykinin [12%]
D. Thrombin [0%]

Histamine is a mediator of allergic symptoms released by mast cells when the body is exposed
to an allergen. Histamine induces bronchial smooth muscle contractions, airway constriction,
and mucus production. During an asthma attack, histamine causes bronchoconstriction which
produces the bronchial tubes to narrow, reducing the amount of air that goes into and out of
the lungs. The image below describes the pathophysiology of asthma and its mediators.

11. What is the primary mechanism of action of Olmesartan?

A. Inhibit sodium reabsorption [4%]
B. Inhibit calcium entry into excitable cells [3%]
C. Inhibit the binding of angiotensin II to the type 1 receptor [82%]
D. Inhibit the activity of the angiotensin-converting enzyme (ACE) [11%]

Olmesartan is a medication administered to treat hypertension that acts by blocking the

vasoconstrictor effects of angiotensin II. It selectively blocks the binding of angiotensin II to the
angiotensin II type 1 receptor in vascular smooth muscle. This receptor participates in the
regulation of blood pressure and secretion of aldosterone, increases the rate and force of
contraction of the heart, and has vasopressor effects.

12. What is the mechanism of action of zoledrenic acid?

A. It causes osteoclast proliferation and osteoclast cell growth [6%]
B. It causes osteoblast proliferation and osteoblast cell growth [6%]
C. It inhibits osteoclast proliferation and induces osteoclast cell death [83%]
D. It inhibits osteoblast proliferation and induces osteoblast cell death [5%]

Zoledrenic acid is a bisphosphonate. It is used to decrease high levels of calcium that may be
caused by some cancers. It is also used to decrease the rate of breakdown of bones in cancer
patients and to help prevent bone fractures. There are three main cell types involved with
bone which are osteoblast, osteocytes, and osteoclasts. Osteoblasts build bone, osteocytes
maintain bone, and osteoclasts break down bone. When bone is broken down calcium
maintained in the bone is released into the blood. Zoledrenic acid inhibits the breakdown of
bone by inhibiting osteoclast proliferation and inducing osteoclast cell death.
13. What is the mechanism of action of Captopril?
A. Beta Blocker [2%]
B. Angiotensin-Converting Enzyme Inhibitor [89%]
C. Calcium Channel Blocker [6%]
D. Angiotensin Receptor Blocker
ACE inhibitors such as captopril, ramipril, and lisinopril reduce blood pressure through
reducing aldosterone’s inhibitory effect on natriuresis.

Valproic acid (or sodium valproate) is a commonly used drug in the treatment of several
conditions including epilepsy, severe migraine headaches and bipolar disorder. Its primary
mechanism of action includes increasing CNS levels of GABA through inhibition of GABA
transaminase enzyme and inactivation of voltage-gated sodium channels. Valproic acid is a
known teratogen with a strong association with spina bifida, a neural tube defect
characterized by immature formation and closure of the spine or spinal cord, as seen in the
picture below.
15. Which represents the primary function of the patient’s hypothyroidism medication?
A. Stimulate thyroid hormone production [21%]
B. Thyroid hormone replacement [73%]
C. Inhibit thyroid hormone breakdown [3%]
D. Increase thyroid iodine uptake [3%]

Levothyroxine is one of the most commonly prescribed medications used to treat

hypothyroidism, an endocrine disorder characterized by low thyroid hormone levels which
may present with various symptoms including cold intolerance, weight gain, brittle hair, dry
skin, constipation, and myopathy. Levothyroxine is a synthetic version of the endogenous
thyroid hormone T4 and is thus used as a form of thyroid hormone replacement.
16. During the appointment, the patient had a sudden headache followed by a fast heart rate,
diaphoresis, and nausea. Which medication will most likely affect the stress response of this
patient?
A. Albuterol [9%]
B. Lisinopril [14%]
C. Hydrocortisone [73%]
D. Omeprazole [4%]
17. Each of the following is an indication for glycopyrrolate EXCEPT one. Which is the
EXCEPTION?
A. Xerostomia
B. Sialorrhea
C. Peptic ulcer
D. Hyperhidrosis
Glycopyrrolate is an antimuscarinic and anticholinergic drug. Anticholinergic drugs inhibit the
neurotransmitter acetylcholine and antimuscarinic drugs specifically block the muscarinic
receptor for acetylcholine. As glycopyrrolate blocks acetylcholine from binding to the
muscarinic receptor which inhibits salivary secretion, it cannot be used to treat xerostomia

18. Which is an oral antiplatelet agent?

A. dabigatran (Pradaxa®) [4%]
B. apixaban (Eliquis®) [4%]
C. clopidogrel (Plavix®) [88%]
D. rivaroxaban (Xarelto®) [4

19. Each of the following is a direct-acting oral anticoagulant EXCEPT one. Which is the
EXCEPTION?
A. warfarin (Coumadin®) [65%]
B. dabigatran (Pradaxa®) [23%]
C. apixaban (Eliquis®) [6%]
D. rivaroxaban (Xarelto®) [6%]

It is not uncommon for dentists to encounter patients who are taking prescription

medications. Patients who had thromboembolic events or are at an increased risk for such
events are typically prescribed oral anticoagulant and oral antiplatelet agents. While
anticoagulants slow down clotting by reducing fibrin formation, antiplatelets prevent clotting
by stopping platelets from clumping. Direct-acting oral anticoagulant agents include
dabigatran (Pradaxa®), rivaroxaban (Xarelto®), and apixaban (Eliquis®). Warfarin (Coumadin®)
is a traditional oral anticoagulant medication, not a direct-acting oral anticoagulant.
20. Each of the following is a characteristic of a direct-acting oral anticoagulant when
compared to a traditional oral anticoagulant therapy EXCEPT one. Which is the EXCEPTION?
A. Direct-acting oral anticoagulants are given as fixed doses. [6%]
B. Direct-acting oral anticoagulants requires little to no routine monitoring. [34%]
C. Direct-acting oral anticoagulants have longer half-lives. [50%]
D. Direct-acting oral anticoagulants have fewer drug or food interactions. [10%]

Direct-acting oral anticoagulants can be prescribed in the U.S. for the prevention or treatment
of deep-vein thrombosis (DVT) and pulmonary embolism (PE). They are also prescribed for
patients with nonvalvular atrial fibrillation (NVAF) to reduce the risks of systemic embolism
and stroke. Examples of direct-acting oral anticoagulant agents include dabigatran (Pradaxa®),
as shown in the image below, rivaroxaban (Xarelto®), and apixaban (Eliquis®).

21. Which is the mechanism of action of methamphetamine?

A. Stimulates release and blocks reuptake of neurotransmitters in the peripheral nervous
system [8%]
B. Blocks release and accelerates reuptake of neurotransmitters in the peripheral nervous
system [3%]
C. Stimulates release and blocks reuptake of neurotransmitters in the central nervous system
[80%]
D. Blocks release and accelerates reuptake of neurotransmitters in the central nervous system

22. Each of the following is a traditional demographic for methamphetamine use EXCEPT one.
Which is the EXCEPTION?
A. College students [54%]
B. Blue-collar workers [16%]
C. Caucasian males [10%]
D. People in rural areas

23. Which is a systemic effect of methamphetamine use?

A. Hypothermia [4%]
B. Psychological addiction [26%]
C. Increase in heart rate [62%]
D. Decrease in blood pressure [8%]
24. Which is the direct result of sympathetic nervous system stimulation from
methamphetamine?

A. Fractured teeth [6%]

B. Gingivitis [2%]
C. Aphthous ulcers [3%]
D. Decreased salivary flow

The use of methamphetamine can cause a variety of effects, including many short-term, long-
terms, and systemic effects. Specifically, methamphetamine is a sympathomimetic amine and,
consequently, stimulates the sympathetic nervous system. As a result of this sympathetic
nervous system stimulation, adrenergic receptors are activated and the direct result is
decreased salivary flow. Note that gingivitis/periodontitis, missing or fractured teeth, and
smooth surface caries at the cementoenamel junction (as shown in the image below) and class
II caries are all consequences of methamphetamine use. However, they are not the most direct
results of sympathetic nervous system stimulation.

25. Which drug is a calcineurin inhibitor?

A. Cyclosporine
B. Amlodipine
C. Cephalexin
D. Hydrochlorothiazide

Cyclosporine, as shown in the image below, is a calcineurin inhibitor. Calcineurin is a calcium

and calmodulin dependent serine/threonine protein phosphatase. It upregulates the
expression of Interleukin-2 (IL-2) which activates T-helper lymphocytes, B lymphocytes and
induces the production of other cytokines. Calcineurin inhibitors are immunosuppressants
used in the management of autoimmune conditions such as lupus nephritis, rheumatic
arthritis, and prevention of post-organ transplant rejection in patients receiving solid organ
transplants.
26. What is a possible side effect of this patient's antirheumatic drug?
A. Hypertension [4%]
B. Infection [49%]
C. Xerostomia [41%]
D. Hearing loss [6%]

Infection is a possible side effect of this patient’s antirheumatic drug methotrexate. Rheumatic
arthritis (RA) is an autoimmune inflammatory disease where the body produces antibodies
against its own joints. Methotrexate is a disease-modifying antirheumatic drug (DMARD) that
inhibits several enzymes responsible for nucleotide synthesis. This inhibition leads to reduced
inflammation around the joint through adenosine induced immunosuppression. Side effects of
this drug may include increased risk of infection (due to immunosuppression), increased
bleeding (due to reduced platelets), temporary hair loss, and liver damage.
Tylenol #3 [4%]
B. Ibuprofen [33%]
C. Acetaminophen [60%]
D. Naproxen

Acetaminophen is the most appropriate medication for pain management in this patient.
Acetaminophen has analgesic and antipyretic properties, but no anti-inflammatory properties
that the nonsteroidal anti-inflammatory drugs (NSAIDs) possess. Although this patient has liver
cirrhosis and hepatitis B, acetaminophen is still the analgesic of choice. This is because NSAIDs
has the potential to cause complications such as bleeding due to antiplatelet activity,
gastrointestinal irritation, and renal failure in patients with severe hepatic impairment.

28. Which is a possible side effect of Isoniazid therapy?

A. Myopia [6%]
B. Heart failure [3%]
C. Adrenal insufficiency [15%]
D. Liver toxicity [76%]
29. Each of the following medications is likely to cause orthostatic hypotension EXCEPT one.
Which is the EXCEPTION?
A. Nitroglycerin [26%]
B. Prazosin [11%]
C. Rosuvastatin [52%]
D. Clozapine [11%]

Rosuvastatin is a HMG-CoA reductase inhibitor used to treat hypercholesterolemia,

hyperlipidemia, and prevent cardiovascular disease. Rosuvastatin decreases cholesterol
synthesis in the liver and with a proper diet will decrease LDL (bad cholesterol) and
triglycerides and increase HDL (good cholesterol) in the blood. The adverse effects of this
medication do not include orthostatic hypotension

30. What is the characteristic of pain that is stimulated by A-delta type fibers?
A. Fast localized pain in response to mechanical stimuli [86%]
B. Slow generalized pain in response to mechanical stimuli [4%]
C. Burning pain in response to chemical stimuli [2%]
D. Dull aching pain in response to thermal stimuli [8%]

31. Which is true regarding broad-spectrum antibiotics?

A. Penicillin G is the most common broad-spectrum antibiotic [20%]
B. They have less impact on normal flora and less risk of superinfections [3%]
C. They inhibit the development of multidrug-resistant organisms by acting against a wide
range of bacteria [23%]
D. They are associated with an increased incidence of Clostridium difficile

35. Each of the following drugs is acceptable to consume with nitroglycerin EXCEPT one. Which
is the EXCEPTION?
A. Acetaminophen (Tylenol®) [8%]
B. Sildenafil (Viagra®) [83%]
C. Loratadine (Claritin®) [3%]
D. Omeprazole (Prilosec®)

36. Which drug is contraindicated in the first trimester of pregnancy?”

A. Heparin [12%]
B. Warfarin (Coumadin®) [57%]
C. Acetaminophen (Tylenol®) [13%]
D. Diphenhydramine (Benadryl®) [18%]
Dental sensitivity can be alleviated by a number of ingredients that may be formulated into

toothpaste, including:

– stannous fluoride
– potassium nitrate
– strontium chloride
37. Which drug schedule has the highest risk of developing a substance abuse disorder?
A. Schedule I [80%]
B. Schedule II [5%]
C. Schedule III [2%]
D. Schedule IV [6%]
E. Schedule V [7%

38. Which type of antibodies are present in type 1 hypersensitivity reactions?

A. IgA antibodies [3%]
B. IgG antibodies [3%]
C. IgE antibodies [93%]
D. IgM antibodies

39. What is the mechanism of action of acyclovir?

A. Protease inhibitor [23%]
B. Integrase inhibitor [6%]
C. Nucleoside analog [33%]
D. Nucleoside reverse transcriptase inhibitors

Acyclovir is an antiviral medication used in the management of herpes simplex virus (HSV) and
varicella-zoster virus (VZV) infection. It is a guanosine analog that incorporates itself into the
growing viral DNA chain and inactivates the viral DNA polymerase enzyme, thus preventing
DNA replication as shown in the image below. Although it has little effect on latent forms of
HSV and VZV, it is used to treat a range of symptoms during acute illness including cold sores,
chickenpox, shingles, and recurrent genital herpes.

40. What is the mechanism of action of dabigatran (Pradaxa®)?

A. Thrombin inhibitor [57%]
B. Antithrombin activator [11%]
C. Epoxide reductase inhibitor [4%]
D. Factor Xa Inhibitor [28

Dabigatran is a commonly used anticoagulant in many settings including venous

thromboembolism and atrial fibrillation. It acts as a direct inhibitor of thrombin (both free and
clot-associated thrombin), as shown in the image below.
42. Each of the following applies to both methadone and morphine EXCEPT one. Which is the
EXCEPTION?
A. Oral route of administration [25%]
B. Natural opioids [65%]
C. Respiratory depression [6%]
D. Pain management

Morphine is the gold standard of opioid agonists and naturally found in the opium poppy
plant. In comparison, Methadone, a synthetic opioid, produces the same effect as opioids. The
image below illustrates this concept. As synthetic opioids are manufactured, benefits include a
higher potency in treating pain and faster production leading to lower costs. However, due to
their higher potency and increased production, an increased risk of overdose does exist.

43. Amantadine is effective in the treatment of which two conditions?

A. Rhinovirus and Alzheimer’s Disease [15%]
B. Adenovirus and Multiple Sclerosis [21%]
C. Influenza A and Parkinson’s Disease [55%]
D. Coxsackievirus and Huntington’s Disease

Amantadine was initially created for the treatment of severe influenza A virus infections, more
commonly known as the flu. As shown in the image below, its mechanism of action involves
inhibition of the M2 proton channel, an unique envelope protein that allows for the release of
viral progeny from infected cells.
A. Inhibit the production of leukotrienes [5%]
B. Stimulate muscarinic receptors in the airway [7%]
C. Relax airway smooth muscle [82%]
D. Reduce airway inflammation [6%]

45. What is the most likely mechanism of action for metformin (Glucophage®)?
A. Nonselective adenosine receptor antagonist [1%]
B. Stimulate insulin release from pancreatic beta-cells [14%]
C. Decreases hepatic gluconeogenesis activity [84%]
D. Blockade of catecholamine release from the adrenal medulla [1%]

46. What drug is least likely to cause gingival enlargement (hyperplasia)?

A. Phenytoin (Dilantin®) [10%]
B. Verapamil (Covera-HS®) [9%]
C. Amlodipine (Norvasc®) [7%]
D. Digoxin (Lanoxin®) [74%]
Gingival hyperplasia is an overgrowth of the gums around the teeth which can be caused by
poor oral hygiene. Certain medications can exacerbate the gingival hyperplasia observed with
poor oral hygiene. The associated plaque build up on the dentition leads to inflammation,
tenderness, pain, redness, and hyperplasia. Treatment is often debridement, and surgical
treatment and excision if necessary.

For the INBDE, it is important to know that drug-induced gingival hyperplasia is associated with
3 types of drugs:

1. Immunosuppressants, such as Cyclosporines (Neoral®)

2. Anticonvulsants, such as Phenytoin (Phenytek®)
3. Calcium channel blockers, such as Nifedipine (Procardia XL®), Diltiazem (Tiazac®), Verapamil
(Verelan®)
A. Antihypertensives [12%]
B. Antidepressants [3%]
C. Oral bisphosphonates [68%]
D. Anticholinergics
48. Each of the following may cause a metallic taste intraorally EXCEPT one. Which is the
EXCEPTION?
A. Acetaminophen [76%]
B. Metformin [9%]
C. Metronidazole [6%]
D. Captopril [9%]

49. Which medication is appropriate in the management of chronic alcoholism?

A. Methadone [17%]
B. Naproxen [8%]
C. Varenicline [17%]
D. Disulfiram [58%]

Chronic alcoholism is managed by alcohol-aversive agents such as Disulfiram (Antabuse ®).

Disulfiram inhibits aldehyde dehydrogenase (ALDH) which is an enzyme responsible for
breaking down alcohol from acetaldehyde to acetate

50. Which is a selective beta-1-blocker?

A. Atenolol [82%]
B. Naproxen [1%]
C. Albuterol [10%]
D. Fluoxetine [7%]

51. An overdose of acetaminophen can result in:

A. Respiratory alkalosis [3%]
B. Thyroid storm [0%]
C. Hepatotoxicity [94%]
D. Myxedema coma [3%]

52. What is the mechanism of action of Levofloxacin?

A. Inhibit DNA gyrase from opening DNA strands [56%]
B. Inhibit protein synthesis by irreversibly binding to 30s ribosomal subunit [11%]
C. Inhibit protein synthesis by reversibly binding to 50s ribosomal subunit [19%]
D. Inhibit transpeptidase enzyme which forms cross links in bacterial cell walls [14%]

53. What is the mechanism of action of furosemide?

A. Inhibition of HCO3− reabsorption in the proximal convoluted tubule
B. Inhibition of aldosterone-mediated reabsorption of Na+ and secretion of K+ in the collecting
duct
C. Inhibition of Na+, K+, Cl- reabsorption in the loop of Henle
D. Inhibition of Na+and Cl- reabsorption in the distal convoluted tubule

54. What is the general mechanism of action of benzodiazepines?

A. They act at GABA receptors and hyperpolarize the neuron [59%]
B. They act at GABA receptors and hypo-polarize the neuron [22%]
C. They inhibit the action of GABA [13%]
D. They stimulate the release of GABA from the pancreas [6%]
What is the mechanism of action of allodynia?
A. Decreased threshold for activation of action potential [65%]
B. Random, constant bombardment of action potential [15%]
C. Inability of neurons to fire and transmit a signal [17%]
D. Weakened synaptic activity over time [3%

56. Which of the following drugs may be used as a sedative?

A. cetirizine (Zyrtec®) [7%]
B. varenicline (Chantix®) [8%]
C. ciprofloxacin (Cipro®) [3%]
D. diphenhydramine (Benadryl®)

58. Which of the following best characterizes the drug receptor activity of naloxone?
A. High affinity, high intrinsic activity [29%]
B. High affinity, no intrinsic activity [57%]
C. Low affinity, high intrinsic activity [12%]
D. Low affinity, low intrinsic activity

The drug receptor activity for naloxone is best characterized as high affinity, no intrinsic
activity. Naloxone is a live-saving opioid receptor antagonist drug that binds to opioid
receptors to reverse and block the effects of other opioids such as heroin and morphine.
Intrinsic activity refers to the ability of a drug to generate an activating stimulus and produce a
change in cellular activity once the drug is bound to the receptor.

59. What is the mechanism of action of naloxone (Narcan®)?

A. μ opioid receptor partial agonist [9%]
B. μ opioid receptor antagonist [88%]
C. Provide cysteine for glutathione synthesis [0%]
D. Serotonin 5-HT3 receptor antagonist [3%]

Naloxone (Narcan®) is a drug used to reverse the effects of opioids. It is primarily used in the
treatment of acute opioid overdose and has therapeutic effects for 1-4 hours. Naloxone is a
non-selective, competitive antagonist at the opioid receptors, and has an especially high
affinity for the μ opioid receptor.

60. What class of medication is albuterol?

A. β₂ adrenergic receptor agonist [77%]
B. Non-selective β agonist [10%]
C. Long-acting β₂ agonist [8%]
D. Muscarinic antagonist [5%]

Albuterol or salbutamol (Ventolin®) is a selective β₂ adrenergic receptor agonist

.
61. Which has the highest risk of infection after needlestick exposure in an unvaccinated
patient?
A. Hepatitis A [1%]
B. Hepatitis B [81%]
C. Hepatitis C [14%]
D. HIV [4%]

Hepatitis B virus (HBV) has the highest risk of infection after needlestick exposure in an
unvaccinated patient. HBV is a partially double-stranded DNA virus transmitted through body
fluid contact (ex. blood, semen) with an infected person. Most patients who are exposed to
HBV will usually resolve the infection within 4-8 weeks without intervention. However, when
the infection is present for more than 6 months, the patient is now considered to have chronic
HBV infection, and this is unlikely to self-resolve. Unmanaged HBV infections could lead to
complications such as cirrhosis, hepatocellular carcinoma, and vasculitis.

A good rule to remember for the INBDE is that for needlestick injuries, the infectivity rate is
30% for Hepatitis B (unvaccinated), 3% for Hepatitis C, and 0.3% for HIV.

62. Which interaction is observed between high-risk antibiotics and warfarin?

A. Enhance warfarin effect through promotion of intestinal flora that synthesize vitamin K
[13%]
B. Diminish warfarin effect through disruption of intestinal flora that synthesize vitamin K
[22%]
C. Diminish warfarin effect by promotion of intestinal flora that synthesize vitamin K [11%]
D. Enhance warfarin effect through disruption of intestinal flora that synthesize vitamin K [

63. Which effect is observed when combining a selective serotonin reuptake inhibitor with a
benzodiazepine?
A. Antagonism [24%]
B. Synergy [53%]
C. Potentiation [10%]
D. Additive [13%]

64. A 20kg (44lbs) child needs antibiotic prophylaxis prior to a dental procedure. What is the
appropriate dosage of amoxicillin?
A. 300mg [10%]
B. 400mg [15%]
C. 1000mg [71%]
D. 2000mg [4%]
l procedures, the standard antibiotic prophylactic regimen is a single dose of oral amoxicillin
(2g in adults and 50mg/ kg in children) 30-60 minutes before the procedure. In this scenario,
the child weighs 20kg (20kg x 50mg/kg = 1000mg); therefore, the child will need 1000mg of
amoxicillin for antibiotic prophylaxis. These regimens are summarized in the table below.
A. Amoxicillin 2g oral [17%]
B. Azithromycin 500mg oral [69%]
C. Ampicillin 2g IV [2%]
D. No antibiotic needed [
1. Each of the following is an antihypertensive medication EXCEPT one. Which is the
EXCEPTION?
A. aliskiren (Tekturna®) [36%]
B. captopril (Capoten®) [1%]
C. candesartan (Atacand®) [5%]
D. bempedoic acid (Nexletol®) [54%]
E. amlodipine (Norvasc®) [4%]

A. Prevents the action of renin [2%]

B. Prevents the release of renin from the kidneys [4%]
C. Blocks the action of aldosterone in the kidneys [3%]
D. Prevents the action of angiotensin-converting enzyme [91%]
3. What is the mechanism of action of nitroglycerin?
A. Causes vasodilation of smooth muscles of coronary arteries through the release of nitric
oxide
B. Decreases oxygen demand by reducing peripheral resistance [4%]
C. Increases the refractory period of cardiac muscle [2%]
D. Directly relaxes the vascular smooth muscle through a lesser known mechanism

4. What is the mechanism of action of hydrochlorothiazide?

A. Angiotensin-converting enzyme inhibition [3%]
B. Angiotensin II receptor antagonism [4%]
C. Diuresis
D. Renin inhibition

Hydrochlorothiazide is a very common medication that is used to treat hypertension. It can be

used on its own as monotherapy for patients with mild hypertension; and can also be
combined with other antihypertensives in more moderate to severe cases. As its name
suggests, hydrochlorothiazide is a Thiazide diuretic. A diuretic is anything that promotes
urination, which is why hydrochlorothiazide is known as the “water pill.” All the classes of
diuretics work to increase the production and excretion of urine through a process known as

diuresis.
5. What is the mechanism of action of lisinopril?
A. Beta-receptor blocking [1%]
B. Angiotensin-converting enzyme inhibition [94%]
C. Calcium channel blocking [4%]
D. Aldosterone receptor antagonism [1%]

Lisinopril is a common medication that is used to treat high blood pressure. It has been
considered the standard in the treatment of hypertension and is often the first line of
treatment. It can be used alone, or in combination with other antihypertensives. Many
antihypertensives work by affecting the renal system; and lisinopril is one of them. Lisinopril
exerts its action by inhibiting angiotensin-converting enzymes. Lisinopril can also be used in
the treatment of heart failure and angina.

The Angiotensin-converting enzyme (ACE) plays an important role in the renal system. As the
name suggests, it acts by converting inactive angiotensin I to active angiotensin II. Angiotensin
II has several functions:

– Increases antidiuretic hormone function

– Increases aldosterone secretion
– Causes vasoconstriction of blood vessels
Aspirin (Bayer®) also known as acetylsalicylic acid is a drug that is used as a pain reliever, fever
reducer, anti-inflammatory, and anti-platelet. Each of these are achieved at different doses
with anti-platelets at lower doses and anti-inflammatories at the higher doses. Men and
women over 40 at risk of a heart attack are recommended to take a daily low dose aspirin.

Aspirin works by the irreversible inhibition of COX-1 and COX-2. By inhibiting these,
prostaglandins are also inhibited. They are responsible for processes such as inflammation,
formation of blood clots, and blood flow.

The prostaglandins inhibited are thromboxane A2 and prostacyclin (prostaglandin I2).

Thromboxane A2 mainly serves to amplify platelet activation and the recruitment of extra
platelets to the site of injury. Prostacyclin mainly serves as a vasodilator and an inhibitor of
platelet aggregation. These two prostaglandins use up platelets at injury sites which causes the
thinning of blood throughout the body.
Metoprolol is a selective beta-1 blocker. Remember, beta-1 receptors are present in the SA
node, AV node, and ventricles of the heart
What is the mechanism of action of digoxin?
A. Increased cardiac dronotropy via beta agonist activity [3%]
B. Increased cardiac ionotropy via Na+/K+ ATPase inhibition [86%]
C. Increased cardiac lusitropy via phosphodiesterase inhibition [3%]
D. Increased cardiac chronotopy via muscarinic antagonism [8%]

2. Reversal of a soft tissue local anesthetic is achieved with which drug?

A. phentolamine mesylate [58%]
B. pilocarpine [15%]
C. diphenhydramine [14%]
D. fluoxetine

Phentolamine mesylate (Oraverse®) is a non-selective alpha-adrenergic antagonist. It primarily

causes vasodilation and relaxation of vasculature, with its primary use being to control
hypertensive crisis.
2% Lidocaine with 1:100,000 epinephrine [52%]
B. 4% Articaine with 1:200,000 epinephrine [6%]
C. 2% Lidocaine with 1:50,000 epinephrine [4%]
D. 3% Mepivacaine without epinephrine

For patients who are taking tricyclic antidepressants (TCAs), such as desipramine
(Norpramin®), local anesthetics containing epinephrine should be avoided. TCAs work by
blocking the reuptake of norepinephrine, which in turn may amplify the effects of epinephrine.
This places the patient at a higher risk for cardiovascular complications, especially those with
pre-existing heart conditions.

3. Which complication is LEAST likely to occur due to local anesthesia administration?

A. Hematoma [3%]
B. Infection [88%]
C. Soft tissue injury [3%]
D. Bruising

Local anesthetics are used in dentistry to help eliminate the pain associated with treatment. As
with any procedure, there are risks of complications associated. From those listed above, the
complication that is least likely to occur due to local anesthesia is infection. The main cause of
infection due to local anesthesia, is contamination of the needle or cartridge prior to
administration. However, with the introduction of single use, disposable needles and
cartridges, the incidence of infection due to local anesthesia has dropped and is very rare
5. What is the maximum recommended dose of 2% lidocaine (1:100,000 epinephrine)?
A. 500 mg [50%]
B. 200 mg [14%]
C. 400 mg [28%]
D. 600 mg [8%]

One such recommendation is the use of 500 mg of 2% lidocaine (with vasoconstrictor) as the
maximum dose in patients.

6. What ion is inhibited by the action of 4% articaine (1:200,000 epinephrine)?

A. K
B. Na
C. Cl [2%]
D. Ca [3%]

Local anesthetics such as articaine are used in dentistry to allow clinicians to complete
treatment in the craniofacial complex with an absence of pain and discomfort to the patient. In
order to feel pain, nerves must undergo an action potential to send the sensory signal to the
brain
Lidocaine (Xylocaine®) and other local anesthetics are membrane-stabilizing medications that
mostly act to block voltage-gated sodium channels in order to block the propagation of action
potentials, therefore resulting in decreased pain perception.

This group of drugs may be categorized based on their duration of action (of pulpal anesthesia)
and potency. These categories include short duration/low potency, intermediate
duration/potency, and high duration/potency. Procaine (Novocaine®) is in the short
duration/low potency category and exerts approximately 30 minutes of pulpal anesthesia.
Anesthetics that fall in the intermediate duration/potency category include Lidocaine
(Xylocaine®) and Prilocaine (Citanest®) and exert approximately 60 minutes of pulpal
anesthesia.
8. Which local anesthetic should be avoided in this case?
A. Bupivacaine [14%]
B. Prilocaine
C. Mepivacaine
D. Lidocaine
Several conditions warrant the restriction of specific local anesthetics to avoid harming a
patient. Prilocaine and benzocaine are contraindicated in conditions like sickle cell anemia,
methemoglobinemia, anemias, and hypoxic conditions and in patients on acetaminophen or
phenacetin. Prilocaine itself does not produce methemoglobinemia, but its metabolite, ortho-
toluidine, does.
A. 5 [8%]
B. 8 [19%]
C. 11 [56%]
D. 13
The FDA and manufacturer of Xylocaine® state that the maximum recommended dose is
7mg/kg, up to 500mg for lidocaine with epinephrine, (4.5mg/kg, up to 300mg for lidocaine
without epinephrine). However, the maximum dose of epinephrine allowed per appointment
is 0.2mg for patients with ASA scores of I-III (with no significant cardiovascular disease), which
equates to the maximum number of cartridges to 11 for lidocaine 2% with 1:100,000
epinephrine (8 for without epinephrine).

Signs and symptoms of local anesthesia toxicity include: apprehension, disorientation and
blurry/double vision. In serious cases, the patient can be unresponsive and lethargic, or can
experience a decrease in vitals such as blood pressure, heart rate and respiratory rate.

10. How much Articaine is present in 1.8cc?

A. 1.8mL
B. 3.6mL [24%]
C. 0.9mL [7%]

Articaine is a type of local anesthetic used in dentistry. It is also known as Septocaine. The
cartridge components of Articaine include a cylindrical glass tube, stopper, aluminum cap, and
diaphragm. A cartridge of Articaine includes 4% Articaine HCL (40mg/mL), Epinephrine
(1:200,000 or 1:100,000), sodium chloride(1.6mg/mL), and sodium metabisulfite(.5mg/ML).
Cubic centimeters (cc) are equivalent to milliliters (mL). Thus, 1.8cc of Articaine is equivalent to
1.8mL of Articaine.

11. How much epinephrine is present in 2 cartridges of 4% articaine (1:200,000 epinephrine)?

A. 0.009 mg epinephrine [8%]
B. 0.018 mg epinephrine [50%]
C. 0.36 mg epinephrine [21%]

The amount of epinephrine in 2 cartridges of 4% Articaine with 1:200,000 epinephrine can be

calculated as follows:

1:200,000 epinephrine = 1 g/200,000 mL = 1 mg/200 mL = 0.005 mg epinephrine/1 mL

solution

1 cartridge has 1.8 mL solution, therefore the calculation of how much epinephrine is in two
cartridges of 4% articaine (1:200,000 epinephrine) is as follows:

2 cartridges x 1.8 mL/cartridge x 0.005 mg epinephrine/1 mL solution = 0.018 mg epinephrine

12 How much lidocaine is in one 1.8L Carpule of 2% lidocaine whith 1:100,000 epinephrine?
R / 36 mg
12. What is the maximum number of cartridges of 4% articaine that can be used for the
patient?
A. 2 [27%]
B. 3 [52%]
C. 1 [12%]
D. 4 [9%]
In this question, we have been provided with the percentage of the local anesthetic (4%
articaine) and the weight of the patient (31 kg). Now, 4% implies 40 mg/ml of articaine
(remember: 1% = 10mg/ml of the local anesthetic) and a standard local anesthetic cartridge
contains 1.8 ml of solution. Therefore, we have 72 mg of solution in total.

The maximum recommended dose of articaine is 7 mg/kg, hence 31 kg multiplied by 7 gives us

a value of 217 mg, which is the maximum amount of local anesthetic solution that can be
used.;

To calculate the total number of local anesthetic cartridges that can be safely given to the
patient (weighing 31 kg), simply divide 217 by 72, which equals 3.01(approximately 3).

13. Each of the following is a reason why achieving profound anesthesia may be difficult in this
scenario. Which is the EXCEPTION?
A. Lower pH of affected tissue due to active infection [14%]
B. Decreased anesthetic absorption [1%]
C. Increased concentration of ionized form of local anesthetic [26%]
D. Decreased concentration of ionized form of local anesthetic [59%]
Local anesthetics commonly used in dentistry, such as Lidocaine (Xylocaine®) and Articaine
(Septocaine ®), are membrane-stabilizing medications that mostly act to block voltage-gated
sodium channels in order to block the propagation of action potentials, therefore resulting in
decreased pain perception.

14. Each of the following are likely signs and symptoms of local anesthesia toxicity EXCEPT one.
Which is the EXCEPTION?
A. Confusion [8%]
B. Nystagmus [73%]
C. Dizziness [3%]
D. Slurred speech
 The appropriate oral analgesic regime that needs to be employed after a dental procedure
should be determined by the anticipated pain level of the patient. For post-operative pain that
is anticipated to be mild, the most appropriate oral analgesic option is ibuprofen 200-400 mg
as needed for pain every 4 to 6 hours. Procedures that are anticipated to generate mild
postprocedural pain include routine endodontics, scaling/root planning, simple extraction,
frenectomy, gingivectomy, and restorations that are subgingival.

2. What is the mechanism of action of ibuprofen?

A. Non-selective, irreversible inhibition of the cyclooxygenase COX-1 and COX-2 [11%]
B. Non-selective, reversible inhibition of the cyclooxygenase COX-1 and COX-2 [83%]
C. Selective, reversible inhibition of the cyclooxygenase COX-2 [5%]
D. Selective, irreversible inhibition of the cyclooxygenase

Ibuprofen is a drug from the NSAID class. This drug reversibly inhibits both cyclooxygenase 1
and 2 from converting arachidonic acid into prostaglandins and thromboxanes. The inhibition
of these neurotransmitters results in the reduction of pain and inflammation. This relationship
can further be understood by viewing the image below

What is the mechanism of action of acetylsalicylic acid?

A. Cyclooxygenase irreversible inactivation [84%]
B. Cyclooxygenase reversible inactivation [8%]
C. Antithrombin III irreversible inactivation [4%]

Aspirin (acetylsalicylic acid [ASA]) is a nonsteroidal anti-inflammatory drug (NSAID) that is used
for its antipyretic, anti-inflammatory and analgesic properties. Salicylic acid has been used for
years due to these helpful properties. The mechanism of action of NSAIDS involves inhibition
of cyclooxygenase (COX) enzymes. Cyclooxygenase is an enzyme that plays a role in the
formation of inflammatory mediators (prostaglandins) and clotting enzymes (thromboxanes).
4. Which is the most appropriate medication for pain management currently?
A. acetaminophen (Tylenol®) [70%]
B. ibuprofen (Advil®) [26%]
C. celecoxib (Celebrex®) [3%]

Patients taking lithium, a mood stabilizer commonly used for bipolar disorder, require special
pharmacologic considerations, as lithium is almost exclusively excreted by the kidney and has a
narrow therapeutic window. Drugs that affect renal clearance such as Nonsteroidal Anti-
Inflammatory Drugs (NSAIDs), ACE-Inhibitors and Thiazide Diuretics can decrease renal
elimination and cause lithium toxicity. Similar to NSAIDs, acetaminophen inhibits
cyclooxygenase and decreases prostaglandin synthesis, leading to antipyretic and analgesic
effects. However, unlike NSAIDs, acetaminophen acts mostly in the CNS and is inactivated
peripherally with minimal effects on renal clearance.
 5. Which medication is most appropriate to be used in providing postoperative pain relief in
this case?
A. ibuprofen (Advil®) [16%]
B. naproxen (Aleve®) [3%]
C. acetaminophen (Tylenol®) [79%]
D. acetylsalicylic acid (Aspirin®) [2%]
The patient presents with various problems, including being on a blood thinner (warfarin). The
mechanism of action of warfarin is inhibiting the synthesis of Vitamin-K dependent clotting
factors (2, 7, 9, 10), with hemorrhage as a major side effect. Ibuprofen, naproxen, and
acetylsalicylic acid are known as Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), which act by
inhibiting the enzyme cyclooxygenase (COX). This inhibition brings about anti-inflammatory,
analgesic and anti-pyretic effects. NSAIDs are also known to prolong bleeding by inhibiting
platelet function, especially acetylsalicylic acid (aspirin); and can cause significant bleeding
when taken concomitantly with warfarin.

6. Each of the following is a side effect of naproxen (Aleve®) EXCEPT one. Which is the
EXCEPTION?
A. Gastrointestinal ulceration [7%]
B. Increased bleeding [10%]
C. Prolonged patency of the ductus arteriosus [61%]
D. Renal ischemia [22%]

Nonsteroidal anti-inflammatory drugs (NSAIDs), including naproxen, ibuprofen, indomethacin,

and ketorolac constitute one of the most widely used classes of medication in the United
States. They have analgesic, antipyretic, and anti-inflammatory effects due to the inhibition of
the cyclooxygenase enzymes COX-1 and COX-2 and the resulting decrease in prostaglandin
production. They are generally well-tolerated when taken at the appropriate dose and dosing
frequency however they have several side effects such as:

1. Increased risk of gastrointestinal ulceration (prostaglandins protect gastric mucosa)

2. Increased systemic bleeding tendency (inhibition of COX enzymes also decreases levels of
thromboxane)
3. Renal ischemia (prostaglandins vasodilate renal afferent arterioles)
4. May cause premature closure (not prolonged patency) of the fetal ductus arteriosus,
particularly when taken in the third trimester
7. Which oral analgesics regime is most appropriate for managing this patient’s pain?
A. ibuprofen 100-200 mg as needed for pain every 4 to 6 hours [0%]
B. ibuprofen 200-400 mg as needed for pain every 4 to 6 hours [16%]
C. ibuprofen 400-600 mg plus acetaminophen 500 mg fixed interval every 6 hours for 24 hours
D. ibuprofen 400-600 mg plus acetaminophen 650 mg with hydrocodone 10 mg fixed interval
every 6 hours for 24 to 48 hours

The appropriate oral analgesic regime that needs to be employed after a dental procedure
should be determined by the anticipated pain level of the patient. For post-operative pain that
is anticipated to be moderate, the most appropriate oral analgesic option is ibuprofen 400-600
mg plus acetaminophen 500 mg fixed interval every 6 hours for 24 hours. Procedures that are
anticipated to generate moderate postprocedural pain include surgical endodontics, surgical
extraction, implant surgery, and quadrant periodontal flap surgery with bony recontouring.
8. Each of the following is a nonsteroidal anti-inflammatory drug (NSAID) EXCEPT one. Which is
the EXCEPTION?
A. Acetaminophen [94%]
B. Ibuprofen [0%]
C. Celecoxib [3%]
D. Aspirin [3%]

9. Which is the general mechanism of action of NSAIDs?

A. Activate cyclooxygenase (COX), accelerating the conversion of arachidonic acid to
prostaglandins [1%]
B. Activate cyclooxygenase (COX), accelerating the conversion of prostaglandins to arachidonic
acid [2%]
C. Inhibit cyclooxygenase (COX), preventing the conversion of arachidonic acid to
prostaglandins [81%]
D. Inhibit cyclooxygenase (COX), preventing the conversion of prostaglandins to arachidonic
acid

10. Which is the most common adverse effect with NSAIDs use?
A. Liver toxicity [15%]
B. Nephrotoxicity [26%]
C. Cardiovascular events [1%]
D. GI toxicity

Nonopioid analgesics and opioid analgesics can both be used for combating dental pain.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered nonopioid analgesics, and
include ibuprofen, naproxen, celecoxib, and aspirin. Although very effective analgesics, NSAIDs
can cause many adverse effects, especially with long-term use. The most common adverse
effect with NSAID use is GI toxicity, which can manifest as nausea, heartburn, abdominal pain,
and bleeding.

11. Each of the following may be an adverse effect with acetaminophen use EXCEPT one.
Which is the EXCEPTION?
A. Nephrotoxicity
B. Hepatotoxicity
C. Headache
D. GI symptoms
Nonopioid analgesics and opioid analgesics can both be used for combating dental pain.
Acetaminophen is an example of a nonopioid analgesic. The specific mechanism of action of
acetaminophen is still unclear, but research suggests that acetaminophen works by inhibiting
the synthesis of prostaglandin in the central nervous system. Although very effective in
relieving pain, acetaminophen use has shown to be associated with adverse effects such as
liver toxicity, headache, agitation, and GI symptoms. Note that nephrotoxicity is not associated
with acetaminophen use.

12. Which dosage of acetaminophen has been associated with acute liver failure?
A. 360 mg per day [0%]
B. 400 mg per day [4%]
C. 3600 mg per day [14%]
D. 4000 mg per day
13. Each of the following is a common adverse effect associated with opioid use EXCEPT one.
Which is the EXCEPTION?
A. Sedation [4%]
B. Constipation [4%]
C. Sweating [4%]
D. Respiratory excitation

Opioid analgesics, such as oxycodone, hydrocodone, and codeine, are used when treating
moderate to severe acute dental pain. Opioid analgesics are often prescribed as combinations
with acetaminophen or aspirin. Opioid analgesics acts on opioid receptors in the central
nervous system, altering the nervous system’s response to painful stimuli. Common adverse
effects with opioid use include sedation, dizziness, nausea, vomiting, pruritus, sweating,
respiratory depression and constipation. The image below demonstrates the mechanism in
which morphine (an opioid) causes constipation. Respiratory excitation is not an adverse effect
of opioid analgesic use.
15. Which is considered chronic pain?
A. Pain that lasts longer than 3 weeks [21%]
B. Pain that lasts longer than 1 month [11%]
C. Pain that lasts longer than 3 months [55%]
D. Pain that lasts longer than 6 months

16. Which oral analgesics regime is most appropriate for managing this patient’s pain?
A. ibuprofen 100-200 mg as needed for pain every 4 to 6 hours [0%]
B. ibuprofen 200-400 mg as needed for pain every 4 to 6 hours [3%]
C. ibuprofen 400-600 mg plus acetaminophen 500 mg fixed interval every 6 hours for 24 hours
[42%]
D. ibuprofen 400-600 mg plus acetaminophen 650 mg with hydrocodone 10 mg fixed interval
every 6 hours for 24 to 48 hours

The appropriate oral analgesic regime that needs to be employed after a dental procedure
should be determined by the anticipated pain level of the patient. For post-operative pain that
is anticipated to be severe, the most appropriate oral analgesic option is ibuprofen 400-600 mg
plus acetaminophen 650 mg with hydrocodone 10 mg fixed interval every 6 hours for 24 to 48
hours. Procedures that are anticipated to generate severe postprocedural pain include
periodontal surgery, complex implant, and partial or full bony impaction surgery.
17. Nausea and vomiting from opioid use can be associated with stimulation of:
A. Stimulation of chemoreceptors from the stomach [17%]
B. Chemoreceptor stimulation of the medulla oblongata [69%]
C. Stimulation of chemoreceptors in the intestinal tract [5%]
D. Stimulation of the mechanoreceptors in the stomach