l'1 ~p.;,,..d by t..f.L Thompson, Ph. D., DepL 0fGen

J, L,,~r this lisl the (lilly osier listed is lelraf:iJltIP.,0, lungs

Plasma00. rvtu~dU}; e. l\iJnt!'y~ 14, 6uptvacaine (MD/caioG ) has all of lhe foHowiny ~lUl-'e111es r~iativ'e

to lidocaine (Xylocaine ) E:XCEPT bupivacaine ~ Is more k17kIC) PWr::iJlntt is all esu:;r: esivl$ a~ met(JJ;oii,tJd ' an ester; eslers ate metabolized predominately bj presence Of which of Ihe iollowing medications? f)seudoel1eJineslerases m tile plasma, but also to some extent a. Prawsin A\l; " i~\\ 'J I" '-',' i /)y ;J$lfHS in (.Iu; liv'er ~ Propranolol l' ,V\. .,' '~ ...e~.,""':' - ,

y Hydrochlorothiazid~ \' :J ~:),::'I-tU_;.._ d. Usinopril ". , ~ "

t~, Digoxin __.. f .2, .All 01 the follO\llH19 factors are significant determinants of the

duration of conduction block with amida-t~-pe local anesthetics ttJ Illis is an inlemction I tesle,d you on several times - now youEXCEPT the {f-l i,J -,' r", "'\ D f know why! Propranolol interacts with lidocaine in two ~

Pn:p;lH:d by ML. Thumpson, Ph. D.. VCP! pf neneral Denuslr)', Tufts DenlaJ ';dlJJl,)j

Questio{)s regardinfJ rO:Cicity:

17 r\ pehMI hal; been glv\:lll J large- "dume of (l teltelin iCC21 :lOe:W1eric solution and si.JosequenUy uevelops CY'l!\O~S \."th methemoglobinemia. Which of the followiJ'l!) dN\jS m~t likely ' ....OS ;lIimlflisleH~d?

" Procaine

\clt>.1'nloC4ioe

'., DiixJl;aine d UdOC.'Ilne t: MepIvacaine

(b} sLrictly memorization

18 Use oj priloC3ine C

c

t7& 0(11y localJneslheik /0 bird (be ffiap1ake aiNEinl(J adrenergic neurons, and thus potentiate ,he NE tnat "'lOS been released from nerve endings

2,1. Which III Ihe IOllOWino i,lnes\l1atic uruYI> IJr,.".h.Jt,;..~ powerful stimviallon of the r.erebral cortex"

--Iii) CocaineY Procaine

Lidocaine d. Tetracaine

e Mepivacaine

(a) see e;r;planaliof! ,~bo,'e

QuesliorlS regarding mechanism of action:

25. Local anesthetic:; bloc!< nerve conduction by a. Depolarizing the ner,e membrane to neutrality o. Increasing membrane penmeability 10 K'" c. Increasing membra.ne penmeabilily 10 Na+ d. Preventing an increase in membrane penmeabillty to K+(.cl Preventing an increase in membrane permeability to Na+

(e) dldnl {make you memorize this? You should at kec:st remember Na+ iOO$ are in\'Ollfed, which lirrnIs your choJCes to (e) and (6). (e) wcuJa increase or facilitate nervous impulse conduction. which is the opposite oJ what you want the local anesthetic 10 do. .)D pick (e).

_ (a) willie some of the oCher allematiV05 sound plaus/Dle !rum '- about lhe factoids you were taught aboullocal ilneslfJelics

26 Which of the (ollowlng is true regarding the mechanism of action 8m;! variables that affectthe/raction. An important one WilS of local anesthetics? rhe rote at pH and ionization factOrs. Remember. the free

3. usuaMy maintain the nerve membrnne in a state of base or nonionizeo form is the form Iha/passes through membranes, yet once inside the neuron only th~oniled forrr.'~hyperpOOrization..

'. b, Prevent the generation of a neNe action potentia!. . is' effective. Intlammed tissue has a lower pH than normal c. Maintain \he nerve membrane In a slate of depoJanzation d. Prevent increased permeability of the nerve membrane to

polassrum ions . e. Interfere with inlra,~f)II\Jlar nerve metabolIsm

(b) this should be really obvious!

27. Local anesthetic agents prevent the generation of nerve impulses by .

a. Decreasing threshold lor stimulation

~ Decreasing resting membrane poten~ial. . . Decreasing Inward movem. ant of SOdlll~l 100c

, Increasing lnwa,d movement of potassium 'on

iC) Answer IS (c)- straight me,?"nzation: newa impul~(iiS .aR generated lJy the influx of sodium nilSUlfmg m dei!oIanzallon repo/anzauon and inactivity occurs when po(as~m moves out. (sodium-potossium pump}. L4s act by blockmg Na+ movement.

:8 Local anesthellcs interfere with the trnnsp?r1 of which of the loHowing ions during drug-receptor Inter

l'1\:):ilreJ by M, L. Thompson, Ph. D., Dept. \if G",nerai Dentistry, Tufts Dem;!j Slhoo.!

d a fTllx!ure 10 times more iQni.z~ than nonioot:ed forms

'C! tne flJlio oJ ionized to unionized forms is oiven b~ trw ,\)1mula log ,A/;'H; pH-pKa. In thi!J instMce the diffdrenCf: i'lcrw.cen pH and ;.;K3 .is O. ThIJS fi(Joc;;im: will ex-1st as an t,>quallT1Jxltn { S.:J (c}..is...L~ MoM Iocsi 8fleSII!8tics ate weak bases IV/Ill pKe l7'mging from i.S to !I.5. L.l.s Intef},j~'e 30 mg. you have to giv,~ 30mglO.5 mgiml or 60 mi. 1cartridge:; 1.B mi. (hus oeml /1.8ml '" 33.3 cartn'dges, ., first express the percentage 01 solution as B fraction of 100. then add the units gmlml. 0.05% equals 0.5 or 1/2 f1rt1$ per 100 mr The cartridge is 1 8 fill which you can round off to a/most 2 rols Ic/aL In tim; 2 mt 1'011 weUld have 1 gm or tha local anesthetic You need 10 ljll'e 3C !;ms, wtlJch would require 30 cartridges. The JltflmaCtve Ihal !Tlei'!S Illis answer is {d}. Don't get !ricxea by the p1aC1iIITJetlt 0' rile decimal point-men, oeople read :he 0.. 05% as 001(10 :re same as 5 gms r3!he,':n3r1 0.5 9m5,

3::. According 10 AHA guide!ine1!. the maxltnUl'11 1: of c.amUies ;;i kx...! 3

L

which IS JUS: below the O.Q4 my /ifTllf

Antibiotics

1. The mO!>l frequently asked type of Question requires you to be able Ie compare various penlQilin anlJDiotJcs in terms of potency agaiNit certain oU9$. '1Ilerg1!rucily. drug ot choice aqainst certain condition;. etc. For example:

19~ a. Penicillin V vS. perleillin ~e latter is more sensitive to

acid deoradatiornmtflflus is usually ir~eCled ralher than taken otaJly (Certainly no one In dentistry uses Pen q. so r would think they would not use too many of the~ questions) ....,... ,.-) I .

...!i..'!" ... ,;.-.. b. &bj~jcillin has:he oest gram-negative spectrum: )".;.~~.:' ..

3:n~~ .r~'. . iL c. Which druQS from a list are Of are not cross-allergenic with

penicillin: most usually asked about ones are: ~a!o~p()tjns and aTpicillln are. ery!hlomydn isn'!..

d. Which peoicililn IS useful against penicilrmase-producing bugs such as staphylococcus; dido)(aciUin

e. WhiCh is speciflc 101 Pseudomonas infections; an extended spectrum such as carbeniGillin Which combill3lion of agents should be used prophylactically for patient witl1 hean vawe to ~event bacterial endocarditis: am..Q!qillln and gentamyon (1988according 10 latestreCOO-lIrie~ of AHA and ADA. although use the lalest guidelines that you have heard about)} (here's a big change obviously. since combinations are no longer used, and neither are doses given before and after treatment- review your latesl prophylaxis guidelines)

Propbylaxb RqilllCM for SBB (Alb\ 1'97 Gilidi:lI~r I" choi"e: Amoxicillin: 1 &(4 X SUO me), PO I Iv before ue2tmcn1. II of pllk)SLbI:.sh~ depends on "# of appomtmef!1S Chlldren:,S,O milkg I he prior

For J"CN all~rgjc: Clindamyein: 600 mg {ot X 1:S0 rng} PO I hr before lJeatmenl. . /I or pills (0 be dispemed dcpalds 011 lio! appointments

""n-onl, Ampicillin /VIIM 2 S, 1i2 hr before (Kids: SO mglk,) Clindamyein (rot !'eNallergic) 600 mg IV 1.'2 hr

prior. kids G!Omglkg)

I'roiillYl.p:r1s(

Prp:lled by M,L 111Omps.on, Ph, D. Dept. uf General DCUUSiri, Tults Denta! ~chool

D, ~~l produces GI upset and pseudomonas colitis. a. Ampicillin

,~lindamyCln D. Dicloxaclllln sodium

.- --- ---_ ..~ {~PenjciUin G procainec Whfdl agf;n\S are mosllikely or least likely 10 cause

-"'if:' F'eniciUin VpotaSSiumsuperinleclion: most: bruad spectrum agents such as

lelrdqcline; least: narrow spectrum agents 5uch as penicillin (el Answl#r is ie)- (a), (ll} i1tId (d) 8rR a/l used orally PfmicilimC~ --

G is deSlroyedl:Jy acid in ihe stornaUI rasullmg inV8niJOle d Aplastic 30ttmia is associateC1 WIth chloramphenicol and irlVgular absorptiOn. PeniCillin V is add stahle and

,_.,._--_. available for oral use. Penicilllll Gprocame IS typically gtt,,-et'l e, liver damage orhepatoto;Jiicity IS associated 'lldlll tetracvc!ifltl intramuscularly in repository form, yielding a tiSllue depot from f. Erythron:!ycin estolate associated with aUergi .....c~1! which the drug is absorbed OVel hours. In /his form, 'I wnnot

hepatJIis be given IV or s.ubcutaneously.

B The principal difference among potassium. proCline ,,!I1d 'I. Questions involving interactions between antibiotics and otller benzathine salIS of peniCillin G is their

drugs: a. Potency b Toxicitya. Tetracycline and penicillin (cidal-static interaction)cancel

eaen other out due to opposing meenanisms of action (it.:t Duration of action ~ Antibacterial spectrum

b. Probenecid alters the fale of renal clearance 01 penicillin e. Diffusion into the cerebrospinal tluld c, Effectiveness of tetracydfnes is reduced by concurrent

(c) again.just asking you Ic know .somethmg awutlhe VilIlLlU$ingestion ~~dairy products forms ofpenicillin. Since in most cases you are going to use Pen

d, Broad spectrum antibiotics enhance the action of coumarin VK orally, thi;t question is an old one showing its age and anticoagulants because 01 thereduclion olllllamiQ IS prOlJalJfy not likely 10 appear anymore ot! board excams ..E9~"'!

e. Antibiotlcs such as_ampiCIllin decrease the effectiveness iJf

oral contraceptives due 10 suppression of normal Gi nora

11. Which at iIle follOwing antibiotics is cross-allergenic with penicIllin involved in rile recycling of active steroids from bile ShOUld NOT be adminislere

; '" WhICh 01 the ;OfiOWing groups 01 antllllGlles is related botl) SIIUC!ur;;lIy ;lnd by mode olaclton to !he peniCIllins'?

a PoiYfl1lins

" Cyclo$eftnes

.~:, Cep/lalosponns ChlOrampO!!fiicolS

~3. FOr It'~ .'JaI1IlSI.It\e most rel!abie melhod 01 ootecllnQ a patie~t's :!fie(9)' to peniolltn is by

~. JI1jeCtlrl9 peruolbn int1;J,,""tm.atty~ Talling a !hOf'ougn mlhllCal hisulI}',

- - P!aonga drop 04 ;;-en,o/IIfl on tne eye

::: Halling the patient inl'la!e a penlo!tin ae!OSc1

e. 1I1k.'(;'Jr\q a small 3ITIOUOt oJ penidl1!l1 intravenoosly

fb~ ,-51f of the ether methtxis IflVOfYE unaccepraDie risic Once sef'lS;UzeC. even a $/T'..aIl amount can cause an aIier-.,ic respcnse, PernemtJer. It is not It aose-rr:lated response tll8t wan 1 lie ,orobiemalic if yOO only ir.jecf a llttJe tNt

1.1 i,hle!'} of the 100lOwmg anlll.:'lCtics is the suhscl;,;!e ct ctloice ref I'-er,iJ.:II!m to tile peniclltn,senMlve patient?

a 8aotratin

;t;:') E:y1htomydn

V Tetracycline

t:. Chloram~d

it;, INy. ,if yO) !la,e!!! M.vd Inis a zj!1iQr! times 0)' ncw.. NoIle Of Uic atfern8ti'ttt",$ itsled tlVOUAJ 00 If problem in ienns or (;fOSS " Wilhin minutes altar drug ~dministration

I. ('0), (I::) and (d) ~. ttl). (c) alld (d)~ ). (o} and {e}Iii

, (bl and Ie) en!)'

v (Cl. I(ll and {e)

e, Penicillin V

iD) :h;;{s why it is ccnSiCeJT:Ki a11 "exte:rnieC-spec:rutn" tOlin (if" pentciilin

,13. WhiCll 01 !l'\e fOllCWlng antlOlctics shc"kl be cor.sldel'ea U'le (:I\.;

ct>c_.;:e In the treatment Ol inlec"Jon caused by a lJI1IcUinase,

;J!'OOUClllg; s:npl'lylococl::us?

a Neomycin t A.~ c T elracycline

"~.c:~.~ ~cjJlII)" - ~'*-~

19 Oral injections caused bv organisms thai produce peni(:l,llna:ot should 0. Ireated ~,1tI j\.___M1picjlllfL_ \.!::) OIdo~aol/Jri" ~ r' 'cfyuvOmyon d. Ally of the atx.'Ve

e, Qfity (a} Of Ie) above

(b) of those IiSfed only (b) is ~niCilJinase resistant. Am/Xillin IS an extended $peCtrIJm penicillin, and is nolpenit:illinase resistant. Erythromycin shouldnt be affected by peniCliimenicft7!n, but it doesn Twork against staph l(1f olhflr reD~O(lS,

20, Wllleh ollhe following antibiotics is LEAST effective againsl 9f! idlli,nasp.-.prod.ucing microorganisms?~I " rnpidllin

, ' Cephelexin c. MelhiCIllin

ct, CHndamyCin

e. Erythfomyon

':' \'Ynich of the follov.inQ is a tacteriodat antibiotic used spec,hc;;;"r In the treatment of intecticns caused by Pseud

Prepared by M.L. Thompson, Ph. D., Dept. ofGeneral DenUStry, Tuits Dental Schoo!

22 Penicillin's effectiveness against rapidly growing cells is primarily rapidly dividing are the cells maj(ingceli 'HaJls Que 10 its etfect on

prOle;n synthesis 37 The action at which of the following drugs willlTlOsllikely be

; ~. , Cell wail synthesis impaired by concurrent administration of tetracydine?

'. . Nucleic acid synthesIs a. Clarithromycin

O. Chelation of melal ions b. Erythromycin e. Cell membrane DelTI1eabili~1 sulfonamide

("~. eniciUin

(b) memorize, memorize \. . Lincomycin

(d) the classic cidal- statigrowth of the microbial poputation th,Br a ~actencldal drug this adverse sida effec!. (C) is the only drug which does both such as penicillin needs 10 be effective. sme only when

G'Boards20D5.doc 9

(,'1ereiore iI's the tight answer.

32 Symptoms that may be characterized 3S anergic rnanifest:ltions Duong peniciJljn therapy are

a. Deafness, dizziness. and.. acute anemia b. Crystalluna. nausea, vomiting and anaphylactic shock c. Oliguria. hematuria, broncnoconstriclion and catdiovascular

collap:>e (~Dermetitis. stomatitis, bronchoconstriction and cardiovascular '''-_,collapse

(d,l

33. Aptastlcanemia is a serious toxic effect that occurs particularly afler a course af treatmenl with which 0/ the (oIlO'....;ng antibiotics?

a. Peniciilin t. lincomycin c. Telr2cydine 0. Streptomycin

((!)yhIOramPhenICOI

--=...-

(el memoriHt

34. Eacll of !he following is a side effect at prolonged tetracycline hydrochloride therapy EXCEPT:

a. Supralnfeclion b. Photosensitivity

c.@vestibOlar distUfbances

d. DiScoloration of newly forming teeth e Gastrointestinal symptoms (wilen administered orally)

(c) memorize

36. Colitis that results following dndamycin therapy is caused by an

overgrowth 01

rns\ C. dificile \.it Staph aureus

c Pseudomonas

d. Candida a!bicans

(a) memorize

Antibiotics, Miscc!l;meous

'Nhich antibiotic is apmopriata lor premedication in the penicillin allergic patient? 2. Cephalexin

~ Ciindamydn

V. Erythromycin

d Amoxicillin

e. Ampicillin

(b) c/irnfamycin is the current recommendaUqn. Erythromycin used 10 be, so if you get a question that doosn! include . c/indamycin as an answer, look~j'cin. Cephalexm miahi be a choice, but ther1i7Sii!eissue o~salf;rgencicity, and it must c~~inJy be a\'oid~.d in the ..' I anaphylactic patienr Amoxlcrliln and amplcJ,lm are penrc!iJms.

38. Acyclovir is useful for treating 3. C;;;ndidi

Prepared by M.L Thomp~on. Pli. D. Dept. ofGener:!1 Oenlisrry. Tutl~ Dental Schad

(c) if iJ can~ do this ii isn1 goir1fJ to be very eitectlVt!.

14. Nystatin is of greatest clinical usefulness in Ireating It. viral infections

; '~)tlJngal infections

'if. spiroctletal infections

d.. Bac!erroides infections e. penicillin resistant gram positive infections

(0) Nystatin is the prototypic antifungal agent, thus (bl is the most obvious 1s/ choice, and eliminates (a). (d) & (e) require an antibiotic, notan antifungal

42 Which of \he following drugs chElates with calcium? 3. Erythromycin

it. Polymyxin 8 (\Ell Tetracycline

'if. Penicillin G

e. Chloramphenicol

(c)

43. Which Qfthe following is NOT dlaracteristicof tetracycline antibiotics?

a. Absorption is impaired when taken with antacids b. They predispose 10 monilial superinfection c. They form a stable complex with the develOping tooth matrix d n1ey have a low tendency for sensitization. but a high-. IherapeuticindexGe. They are effective. substitutes for penicillin prophylaxis against

infective endocarditis

Answer is (e)- Again, !he important phrase in the question is. not (Hfty, just Wayne and Garth). Obviously the fact thai you will remember about tetracylines i$ tfl8t they can discolor leeth in the fetus when taken by the mettler during pregnancy. But don7 circle that answer because (a) is also characteristic a/tetracyclines (they are file mcstHke!y of aU the antibiotics to cause superinfection). 3Jld is an annoying side effect in adults resulting from alteration 01 the oral, ga.sinc and intestinal fiora, The real answer is (e), Tetracyclines are not (he dru~ of choice for prophylaxis against infective endocarditis. This is dve to streptococcal infection. 15-20% of group A streptococci are resistant to tetracyclines, btA none are resistant [0 p8f1icitJ1n or erytllromycin. Recently a noft.. streptococcal induced subacute bacterial endocarditis has been identified, t1specially in juvenHe periodontitis patients The causative bacteriumis not susceptible to penicillin or erythromycin. II may be necessary to treal predispcssd patients with tetracycline far a few weeks. and then follow lfli$ Wltti

--

Cardiovaseu13r Orugs

TIllS category a.W;?fS 3 101 Of

PrcplIf::d by M.L TIlOmp:son, Ph. D., Dcp!. of GCIICIlll Dcmi:.luy, Tufts Dental School

arrythmia

3 ~.[apamil is most efficaCioos in the treatment of fa.) AtriaJ fibrillation V Atrial tachycardia

c VentnculClr tachycardia U. Catecholamimj-ind\JCBU Olnflylhmias

(a) memorize

J Which of the following drugs is most useful in treating or preventing angina pectoris?

a. Digitalis$Quinidine

.' .: Propranolol

- Procainamide

e Pentobarbital

(e)

5. Each althe following drvgs can be used in the prevention and 1'iJ.1m.enl of angina pectoris EXCEPT.. , a .. DiQi!alis

Propranolol

c. Nitroglycerin d. Isosorbide dinitrale e. Pentaerylhritolletranilrate

6. Ail oj Ihe following drugs are useful in the !Ieaiment of hypertension

.. a Ephedrine

Reserpine111EPT

c. Methyldopa /JJ,d Thiazide diureUcs ct, OJ!

(a) ~Or y ~ O. I 4 ''-/"'

7, Digitalis is useful in the treatment of which of the following ~ conditions? Yd---) ...

@ Chlorothiazide e. Alpha"methyldopa

(ED 10. Which of lhe follOWing anllhypertenSlves are usually reserved lor

lre41tment of severe hypertension? a. Scdams and roserpino b. Thiazide diuretics and reserpine

(~ Sedatives and thiazide diuretic;s

~Guanelhjdine and ganglionic blocking agents

(d)

11. Which of the following beta-adrenergiC receplor blOCking agents is thought to be cardioselective?

a. Naoolol TimOIOI ~MetoprOiolc.

PropranOlol

(e)

Mechanism of Action Questions

Antlarrhythmics

12, Antiarrhythmic drugs, s\lch as quinidine, suppress certain cardia: arrhythmias .by

a. Stimulating the bela-adrenergic receptor b. Suppress.ing cardiac ATP-ase activity

(~ Increasing ectopic pacemaker acUvlly

'\,JJ Increasing. the refractory period of cardiac muscle

(d)

13. Most drugs useful in the treatment of cardlacarrhythmias act primarily by

a. Blocking Purkinje fibers b. Blocking the alph

(b) arrhythmras are defined a$ any abnormality 01 the normal st'nll$ rhythm of the Malt due to disease Of injury induced damage to the impulse conducting systems. They also result from the development ofectopic pacemakers Of abnotmaJ paceml3ker mythl1l$, Dtvgs stJCh as Iidoclline are used to oOnnaUzs these rhythms. Lidocaihe, a local anesthetic. depresses cardi" eJCCitability. answer (b). The relniclory period of cardiac' f7IIJ$de JS IriCreased. thus sfowing the heM clown. All of the other alJematives given would exacerbate Ihe arrhythmia.

16. When digitalis is used in atrial fibrillation. the therapeutic objective IS 10

a Abolish cardiacdecompensalion

PII~pa"l!d by M.L Thumpson, Ph, D,. ~Pt ofGener:)! Delllisrry, Tuns Denral School

a, Activation of adenylcydase b. Inl1ibllJOn Or phosphOdiesterase ,... . An agonist effect of bela-receptors

, ~d, Inhibition of Na+. K" ATPASE leading to increased calcium 'innux

e Decreasing the amOunl of calcium available for excitationcontraction coupling

Answer IS (d)- Remember. cardiac gJycosides such as digoxin are used in the treatment of congestive heart failure, which is the failure of the heart to function adequately as a pump and f/1us ma/nlain an adequ8te CircUlation. Cardiac glycosidesaro IflOughllo act by altering calcium ion movement. with a desired eifecl of increasing the force of contraction of the myocardium (e,g. the inotropic effect). While several of the aiternatives involve calcium, /he way digoxin does it is via (d), innibition ofNa+, K+ ATPase, resulting in an increase of calcium ion influx into the cardiac cells. and a subsequent enhancement of the contractile mechanism. (a) ;s the way epinephrine worl ts

(a). (b) and (cl ii. (3) and (c) only iii. (c) and (d} IV. (e) only

@ All of the above

I'. ,M ;

29 The; cardiac glycosides '0\111 increase the concentration of ,vhich ion in an active heart muscle?

a, Sodium b, Bromide

en. C .. iol,lmcr Chloride

e.. PotassIum

30. Which of the lot/owing ions augments the inotropIC effect Qf digitaiis?

a, SodIum$. Uthillm C,,' CaJdum

Chloride

e. Magnesium

(c)

31, In lhe treatment ot congestive heart failure. digitalis glycosioes generally decrease all ot the fOllowing EXCEPT

,~~~~~ow c. Heart size

.'d.'- Heart rate

.e. Residual (jiaslolic vOlume

(b)

Adrenergic Agents

32, The mechanism of action of prazosin. an antihypertensive. agent is 10

a. Block beta-adrenergic receptors b. Inhibit formation 01 angiotenSin II c. Inhibit nerveinduceCl release of norepinephrine

,...d. Stimulate central inhibitory OIlpha-adrenargic receplors (@.Inhibil ltie postsynaptic action of norepinephrine on vascular ",-.,'smooth muscle

(e)

33 Which of Ihe following owes a significant amount of its

lihypertensive effect to a cenlrat action?

a. )Meu"yldopa , . Metoprolol

c, Hydralazine

~ d. Propranolol e. Guanethidine

(aJ Ail or ihes/l drugs are used to treat hypertension. but ael by different mechanisms, (a), methyldopa, is the drug with cenlral action- it atters eNS conlfo( pl blood preS1!1jl by acting on cardioreguiatory and v;;lsomotor systems of the brain by stimulating a/pha2 receptors in the brain stem Cfonidine is the usual drug Ihat is inllolvedin /his psr'dculW question. (D) metropolol is a se/ecllvely bloCK$ be/a-1 receptors in the heart to reduce cardiac output. Ie) hydralazine has a direct action on vascular smooth muscie tv reduce hypertenSion via vasodilation, (d) proprano/oll:liocks beta receptors in the heart, while (e) guanethidine E!.~l'!nI5 /hJUf:&ase and ceJUses depletjon of catectlolamines takenyp iDto..stoiagevesiC:les.aridhifeleased like a false transmitter It dOf}S,[l9t cross the bIoodbr8in barrier

,34, Which ot L'le lollowing drugs is thoughl to reduce 3 rteriaI blood pressure by activating alpha receptors in the vasomotor center o! the medulla? (7

.' fii.... Prazosin ~c!onidlf)e

(i \Boards2005doc

c. PropranolOl

d Guaoelh,dine

e. Clilcrottliazlde

::5 Prop:anoio{. (In''':erail C3n 00 usefulln me tJe,wne.nt ot

h; ;x::nens;on o.:.ca;;se It t'>lo;s

.9 AJpha-l aa-ner;JtC receptor'S

b. Sodium reansorplioo in the kv.lney

Ie ,The rele.ase of rer.m /rom jl.lld"glomerul2t ceL's

';rThe release ot ~Ine from newEl terrnirl.ais

'e rhe rdex ta;:;!l:C3IC!ta seen with Itle use of omet

a"III1~-pertensl"iiS

ili) aWl It;

fllaN {v)

Ii; Ill), (e) and (ol

k\,.' fe). (o)anu (e)

'\:.) (e) anc {~J only

i./ A.n&W~ .$ (\;

~ DeCl'ea5e(I PR interval

.!D-., Admtnisn3r;cr 01 'f.hid1 of tile f'ofk.1\ving artr.:)s inetea5eS tt:e i~~lmooo ct :l 10,,",C ;esponse Ie dici!alis'

a. Oiaze:::am b Liooc:a.ne "~'"Sp;~

Prcpan:d by l'v1.L. Thl.lmp;son. Ph, D" DqJI. ofGcIlcrlll Dtlllistry, Tufta 1)I;OI&j Si:hooi

Analgesics- NSAlDS:

. Mechanism 01 action questions regarding analgesic. antipyretic and

effects on bleeding:

Analgesic effects: aspirin inhibits the synthesis of

prostaglandins '*

Antipyretic effects: asplrin inhibits PG synU1Ersis in the

hypothalamic temperature regulation center

Bleeding time: inhibit synthesis ot thromboxane A2 preventing platelet synthesis'

2. A 2nd type of question has 10 do \!Jlh pharmacological or laxi

Wail, roo s.houI(f f1f!alfy knaw thaI a(;e/&mir';;:pI!en I" tJSUd'!' the 8Itslvcr10 lht!tse types ofanalgeSICs C;uesticns, but" ,,;0,, didM ktlowl!lal., pernaps you may knew thai aJronoi ,aiSi) c:auSBS Gf !f1itation, sO it is OOt.

1(l v;hich ollhe foU~ anli-inlldinmalo"lbtlng adi..ty of PCC5taglarnjin synthetase'"

,c.. OIt!l.II'!isal

IDuptoten

Tnamclnolooe

OX) phenbutazone

Ac.e~lIcytc ace

te} if Ctlly "-">W'I!1'S ,'feU/' t~m;Je:ature J you r..,lti ,< ,',,; ,"".'~-

Prq)llf(:d by M.L Thompson, Ph. D., Dept. of General Dentistry, Tufts Denral Schoul

a. Occult bleeding a. Ibuprofen O. Nausea and vomiting b. Oillunisal

_"', '--.. they don'task somany questions on these drugs Jnymore. J~"'\Hepatic necro~is . ~ . ~'-'fl'' . , , YGaslnculceration ' ( .1.,'(/~ J,.',' .' ..,

:... Additional drug identifications they always asi< involve knowing e. RespiralOl)' alkalosis :'>1.J..-:!.. '--". J that naloxone is an antagonist used 10 'real oVDrdose, and thaI

meihadone is used in detoxification of morphine addicts Ie) Remember, acetaminophen (lrlenoi) is an asplIin

alternative. Alternatives 1, 4, 5 are side effects of aspirintype 3 Some Questions give you a list of pharmacological effects and

drugs. The populanty o( acetaminophen as an 8spinn ask you to identify which is nct an effect of morphine. MOrphin

altemative is because the incident of such eHects with this produces respiratory depression, euphoria. sed31i.O.D. dysphoria.

drug is very low. However, because acetaminophen can. analgesia, and C~Ollaruj Ul'1nar:y~nli~ The .

undergo biotransformation to 8 toxiC in(9l'11lecliate, hepatic and :rotmiID1fon they otten make Is aiarmea Jor constipation, Of

renel necrosis have been reparted, especi$lly after very higfl perhaps diuresis ror urinary retention. \/11.

doses (c). hepatic necrosis is the most prominent. especially \No

when combmed with aJcchol consumption, since the alcohol 4. The last most frequently asked \YP of question regarding

induces the liver enzymes which make the hepatotoxic opiates concerns overdose 01 toxicity. In overdose morphine

causes coma, miosis, and respiratory 'p~p(essiQn. Sometimesmetabolites 01 acetaminophen they asTthemeCfiarnsm of respiratory depression: loss 01 sensitivity 01 the,..meGu!lary resplratory.center 10 caro.o~di~lde

Which of the following anti-infiammatory agents does NOT act

primarily by inhibiting the activity of cyc!ooxygenase? Frequently as.ked questions on morphine:

19

5 Occurrence of which of the 10I10I.'.1n9 is LEAST characteristic of narcotic iflgeslion?

VQfTlitlng "

~ t). Diarrhea

_ . Urinary retention

d. oronchiolsl constricllon

(0) Again, the key 'Nord IS /es1. Narcotics, in the (olm of paregoric (tincture or opium), and lomotil (lope/amide) are over tile counter oral preparations for the Ireatmell( Of diart1lea. Oplales act on n;ceplors in the gut to p.wuce constipation. Tllus (11) is obviously wrong. Ail of tile othor answors are side effects of opiate administraiion.

Dc Therapeutic dos.as of morphine administered intramuscularly may proouce

a. Constipation

b Euphoria

c Qysphoria

d. Mentai clouding

e Decreased response 10 pam

I Ill) and (b} onl)' Ii. (3), (b) and (d) iii. (a). (dland (e) iv. IC). (d) and Ie)c:J All of the above

tv) memonle

8. Which of the following are phaml::)cologic effe

PrcpiJ'cd by M.L 'nlOrnpsnn. Ph, 0, DePL ofGeneral Dentistry, TuJh Dental School

briJinstem 10 the carbon dioxide tension of the blood, and also therapeutically an advanrage, but it seon becJme depresses pontine and medullary centers regulating apparent that (a) was also true respiratory frequency Opioids do flot cause oxygen apnea, ((a)). they can be convulsive, but not ferminaily so (e)). they are stabilizing on 11113 nf!att and some are Be/UEiUy used in 18, The antagOOi.st of choice in tne treatment of upiuid overdosage is open-neartSlJrpfJ[Y ((b)), and /hey do not cause circulefory _ /5') Naloxone collapse (d)) '( Nalorphine

c, Pentazocine d Levallofpllan 8. PropQxypnene

:4 Which of Ihe following is an opioid that has both agonistic and antagonistic activities? (a) naJorphinl] and pentazocme ale mrxed agOOlS(

a, Codeine an/agMiss. /evaJlorpllan is an opioid lIgOIlisl. a:; IS b Methadone propoxyphene c, Naloxone o Meperidine

,1J!) PentazOCIne 19. Which 01 the following IS J cornplele antagonlSi oi theoplol(j

receptor and the agent of c.hoice in tt)e treatment of narcotic

overdose? .

class j~ given. You are asked to not only kJentify a dftlg from .--(J) Naloxone the Jist as being from this cJass, but additionally that it has the b. Nalofj)hlhe properties that are given in the question that distinguish it c CydazocJne from (he other drugs of the class that are fisted as (L Levallorphan alternatives. In this example, there is only one drug Y\llich e. None of the above meets this criterion. All are drugs which act Ilia opiate receplars. but 3 are agonitIS ((a), (bJ. (d)}. 1 is an antagollist (a) reworded verSIOn of tile preceomgqueslioll only ((c)). (e) pentazocine is/he only drug wflich has both types of action, and is the olle drug ref! by the process or elimination.

(I} This i~ an e.Hllnple of (he type of question where the drug

20, Metl1adone is used in detoxification (drug withdrawal) of patIents physicaRy Ileper.dent on morphine because methadone

a. Precipitates withdrawal reactions b. Antagonizes tile depressant actions of ffiOfphrne ~ Wllf not in Itself produce physical dependence15. A tH:!romdependent patient should NOT be given nalbuphine

INuCaill ) tor pain because ...-~ Wilhdrawal reactions are less intense and stresslullhnn ~olmorpl1it1eu It has no analgesic propediea Jl II may produce respiratorydepres.sion

-i.V As a mixed agot1isl-antagonist. il ,.an elicH withdrawal (d) This is an example 01 (fie kind of question (hal requires IMI jQIJ flsve memonzed a fact about a parlicular drug. tn thISsymptoms

d The high abuse potential DI nalbuphine may add to Itle co.se the fact is (d), Methadone you will remember IS no{ an antagonist/ike naloxone- it is a full agonist with analgB SICpatient's problems proper1Je$, just like morphine. When taken oraily it i3 no( euphOJic in adr:flC/s. but acts justfike morphine to produce(c) see above tolerance and physical dependonc(J, Withdrawal is Jess severe than with morpIline bec8u.s8 me/hadooe has a much

16 A patient while not currently taking dnJgs has 3 history (6 months Ior.ger half /ffe, Facts 1. 2, and 3 would be mel by an antagonist s;Jch as naloxone, or perhaps even it rnixeo

"gO) of narcotic dependency, Wl1idl of \l1e following analges:s agonist-antagonist sucft as pentazocine,sMuld be avoided in this patient?

A ASpirin

\.S) P.enlazcine

21, I-Vhich of the IQl10\...in9 drugs is currently \"';IJely used in treaHng C. prcpoxyphene opioid..oependent individuals? d. Indomethacin

e Acetaminophen R. Cooeine ~ Met.'iadoi.et None 01 me aOOve c, Alphaprooine d. Pentazocine{b) see above c, Meperidine

(b) shonened version of the ai)ove question1i, Which of the following statements does NOT cttaractellze pentazocine?

a, II is eqUlan21gesic Wllh codeine 22, f\.1eperldine (Dernero!) is b, II 15 a paT1ial opioid antagonist -'=' Art antidepretsant

c Its abuse potential is less than thaI of naroln lSI An cpiold analgesic A It may induce dysphoria and menta\aberralions c, A sedative

'\!j II is effedive only on parenteral administration d, A iOllgacting local anesthetic e An anllpsyd10tic(a) 101 of memorizatiQ/1 requited here for a drug thai [:sn't

used that much. I guess it was big news when these \b;quesfions were written many years ago and they seemed

hopeful, since statement (e) W

any actions 01 their own. theyjust pmwmt AC.'1lJff(Hj$lly tJIodOOg teCSp(ors: tJlrOfirIe and propBnthelillfl' aro

Autonomies: po3tganglicniC muscarinic teCeplOfblor:kersthus the .:l('S''''t''is (

hepared by lYI L Thompsnn, Ph D" Dept. of General Dentistry, Tufts Denla.! S

moke it worse like the barbiturate $edativesdo! Promethazine is 3nlill1tihisi(tmine used (Of 1M sedation. Looks 10 me $0 far that they have thrown in a lot of drugs used in 3 Ouestions regarding physiological actions ofcholincFflJc dru9s~sedatioo context. and expect you to know which one is ill the mix 10 control saOvation. Physostigmine is an an/ic:/lolinesteras - why is thai in this list? Diphenhydramine is OK. here's an outline 9f cholfnergic stimulation effects; Sanadlyl. a velY sedating at'Itihistamine that is used as a sedation agenL In a pre 'o'IouS questiOll Jdiscussed propanlheJine as Pro-Banlhine, a synthetic atropiM type drug - 50 this would work to dry up the oraJ cavity. What I don t like abcul this question is that the anti/listsmines area/so anticho/margic and will have adrying acticn. rguess Ihe (!iSII/JClian from propantheline is that it doesnT c;aU5rJ sedation, 50 is more $erective for just drying up excessive salivation - so if you want only that effect and not /he sedative action as well, a drug /ike {KopantheJine is beller.

13. The most useful drug to induce salivation is aile which has properties that afe

fenergiC ( bJ linergic

, angllonic blocking

~

d. adrenerqic biockitIQ e. cholinergic blocking

(b) well. lhis is just the opposite way of askingwhal was asked in /he ather questions given herellfantieholiMtgic agents are useful to reduce salillation, only an idiot couJdn! figure oul that a cholinergic agent would be useful to induce sa//IIIJtion'

14 DWQs that are commonly used in the control ofaxcessive ~alivalio!1 include

(a) mePlOOamale --.... (o) illI'Opine

" '(el methantheline

(0) codeine (e) chlorpromazine

,. (al and (b) only

(a). (0). and (e)~(b) and (C) only

:-{b). (el, and (d)

5. (a) and (e)

(3) you are probably thinking, who the hen ever heard of meprobamate andmelhanlhefine. or for /hat matter, chlorpromazine! Weil, these are drugs t!1I11 may ,'lave /Jeen useful in the olden days, but would bc probably rep/Dee in IIlis type of questions by 1TlCf9 moc!em equivalents. Bul or course you should figure out that atropine (b), being the protolYDe antiCholinergic drug has to be one of the answe~. So option 5 has to bee incorrect. since it does net include arropine. Now only the most corrupt dentist woulr:f prescribe cod(line to reduce Si'lliystion, so #4 should also be incorrecl- /hai leo ves 1. 2. or 3. $0 see, }'QiJ didnt even have to recognize thai cfllorplomaZlile is an antipsychotic drug. So what is meprobamate - if we can eliminate tt,"t one then we are down to only option 3 as a possible answer. Meprobamate happens to ,,~ an antiilnxiety, ske/elal mV$cie relaxant drug sometimes used by dentists 10 treat muscle spasms associated with TMD - also has lise for e;:temOlt sphincter spasticlly - imagine! But ildoesnl seem to !lave anticholinergic activity that is significant e~oufl.h to cause . significant reduction of saliva. Methan.lhelme, III ~OfltIast. IS 84r.rhine, a syntHetic version IJf atropme! So 0P!)Ofl 3, atropine and meU'8f1lheline are rhe drugs (or thIS purpose,

Eye: miosis and reducUon oflntnJoculaf pressure CV: bradycardia; vasodilation (but only from injfKted cholinergic

agents, since the muscarinic receptors on the Vi/seuaJr smooth muscle has no neurel input)

Gl ITact: increased spasmodic activity, increased saliva lien and acid secretion (Ovflrdose: nausea, vomiting. diarrhea)

Urinary trac:t; incre;lsed urination Respiratory: bronchoconstriction Glandular: lacrimation, sweating Skeletal muscle: tremor and at;a;cl. (overdose: muscle weakness,

cramps and fasciculalions)

Anticholinergic (antimuscarinicl actions are the reverse of th~ above:

Eye: mydriasis and loss of ac{;omodation and increase of intraocular pressure

CV: increased heart rate (overdose: tachycardia)

GJ tract: decreased spasmodIc activity. decreased salivation .iwd

acid secretion (overdose:) Urinary tra(;t: decr.east:d urination Respirator.v:bronchodffation Glandular: decreased /Olcrimation, decreased swea.ting (olferdose

hot, dry skin. hyperthermia) Skeletal muscle: no efftcts, since they don't act on nicotinic

receptor.s, only muscarinic eNS: tertiary amlnessuch as atropirle get into the brain ;md .

cause restlessness. headache, excitement, hallucinations and delirium Quaternary amines lfIr.e methantheline and propanthelfne ollly have peripheral actions

15. Adminis1ra!ion of ganglionic blcd

P!ep;uoo ill' M.L Thompson, Ph. D., Dept uf Gmcral OI;ntistry, Tufts Ckntlll Sd'too!

tb} . Atropine and scupoJaminfl are I71U$carinic c.haiinergk receptor bJocxers. Just kl!OWiflg tIIaf &Ifroinatas aif the altemstAtes except /lJ) But you 5IIOUId 8WJ remember tIlfil .'letll1 'BU! is kept under tHlItt rdeldw r;cnttol 811)' sudden 1f'lCfr'-8Sh in HR usuaJty stimtlBtM btJtOteCeptOl'S to rend a S.if!1181 to 1M vSOUS netVfJ to stIttwJMe !he heNt to slew it bnck '1OWfI. This reflex is CIIOIinergiCtJJJy mediated. and will be blocked by c.hoIinef!7ic blockers svdl as atropine. Even when gllrl?fl in the absence ofhigher than normal heart rate. atropine will bJock the normal cholinetgic conlrol owr Ihe h.,srt, lealling the sympathetiC system io charge with a '1i!sul1ing tachycardia.

1 7 All ()f Ihe following are possible effects 01 cnollnomimetic drugs !~xCepl mydriasis

b. bradycardia c increased penstalsis a. stimulation of sweat glands e increased secretion by blonchial glands

(a) The rlf!>! thing you have to #!.noW is that II cholinomimelic drug is one that mimics t~ action of8C4tylchofme. the endogenOuS neurotransmittet in the patBSympathelic or cl'lOlmergic fIef'I'OUS system. The aat1Il)'ffl for IfimemtJeti!7g Inc effects at~ $timuI8(iQn is SLUD, or incIeassd :saJNaliott lacrimatiOn. delecaOcn. ;md utination. The Marl. is tne esC'epUoil in lIIat activity Of flearl rate IS decreased rl:.-raoycarriia)-liws SIOCe the queslloo asks lor a.neffec1

~hlCh dOIi!J~ nat occur with CIJIifleffJIc stimUlation. thai iesves (iJ,i;iS the only possibility. Mnsis, not mydriasis. oct:uts with C1lJ11lef!7ic stirrnJaticn,

18 A paraly:ing dose ot suconylcholine ~ eliCits NS stlmulation ~.NS depiession

. tlecrElased salivation d. uSCIe faslculation \!. extrapyramidal reactions

(d) becslJse succinylcholine iSUX) is 811 agonist 81 nicotinic receptors, SO the initial response is muscle stimulation. BUi tho NMJ rapidly cJepolariz(J'5 due 10 the Inabilily of the plasma ctlolinestersStllo l>feak down the SUX. which isjust two toolflculesof acetylchclIne fused Iogether - the other inlannation has no Ie/evance unless you're iust stuck thinking "gee, t know that SUX has something 10 de WIth autonomics bul not sure e.xactly what!"

19 BaSed on ,ts kllO'."o mecl1anislT1 an

23. The ITlOIlt tikely $J9Il$ or symplOlTl$ of ov~ with alrOpioe

aGJCNS Qlr.ci\!l!lon nnd ladlycan:fia b. irtlesttnal Ctamp$ ana dJannea c. skln msh and 0I1aneous ItcfIIng

il ptyalism anO inUua5ed SMating

e. COO$lndion 0# \he pupdS and blurring at v!sioo

fa} jUst when you tttoog/lt you could gel by with the anJi.$LUD strategy. tMy mell ttxpect you 10 ~ that atropine Q\'flrdose causes eNS excif8tion ami~? Actualy. that IS one of the lfIletesql'llfs ~ atropjne ana

$~, and the 1'N$OIl fI* ~ lis used lor seda1ion. ~ ItJT>{JII'Ie iSn t (bJ and (e) I1'f ~ ~'fll t/lttlI(. Ie) r.s l'Ii.mImtIne ptOduced. while (haven! gil( iI ellJe ""nat "'ptyalism' is - do you? &It f 0I:l A:rlQW t1Ial jf 8lrQpine c""ses arr tIOt skin ~ it prevetlt$. ~ then (eJ} c3n1 be ngtttJ

24. OtsoOentallOtl. conlu:Horl and ~ resulting from an ~ Of ~ ate most ef1lc:aciuo.sly Ire3Ied ~

a~lel'ing

a atropine b. Ievt:xklpa

~~ (d1 so ya gotta hncw scopolamine i$ anIiCbaIInergic. so ya need a cnClitler'fPC agoni$t., IIilhitN direCt Ot indinI.d to owm::orne ds erfltCts. The options in the fi!t ate c and (d), Acer,.h;hcIinc won' WQ(k tcause it gets /lroIo;sn dovm way /0 (lJpiClly by .acetylcllolinestenue. and ttIUS is IJ~ to inject PhysostiQmme ""ilI warlI: since it is an indifect acetylcholinesterase.

25. The immediate cause of de:.llh from irreversible cholinesterase inhibilQrs is

a. shack b convulsiOn A cardiac arrhythmia

(gJ respiratory paralysis .

e. d"h~atlon from vomiUng and dlarmea

(d) - wht1e some of these ate indeed Bssocialed with organophOsphate IOIt1city, the immediate cause of death is aue 10 (d), which results from the stimulation of nicotinic roccpfQrs at the ncurQmuscularjunction resulting in paralysis of Skeletal muscles,

25. Each ot the following is .. symplom 01 cIiAdntner-gics;

1. Drug idenllflcadon l}1le queslions !hat IIlvolve med1anism 01 action. Yau need 10 know the follolWlg !)pes of facl.s:

a. Receptor blockers: alpha Of bela adrenetgic drugs $l,I01 as

ptazoliin Ot ptOI)f8I\OIoI aet by compe!lIIve inhibition 01

poalfunctional adrenergic fltC8ptors

D. Drugs lhat inhjblt the acIlon oj adl'enel'{/ic nerves' i. Reserpine; dspletes NE by inhlblling reuptake ( d!if htv-. otN~ -:'J.tr) il. Guanethidine: inhibits the release of cated'loJamrnes( ftJ G) iii. Alpha melhy1dopa: acts centrally is a false .

neurolraNmilter 'Nh1d1 gets taken up into storage v,sides and released with NE. thus decreasing sympathetic actlvlly

Iv. Clonidine: stlmulates alpha2 receptors in eNS with a

resulting decrease in 5ylTIP3tnetic outflow

c. IndfU~d a

epa.led by ML Thompson, Ph. D. D~t. ofGencrJl Detuistry, TulhDcnr:a\ School

slimulale vagal reflex 10 reduce helilrt rale. V393I feflex is blocked by atropine

nus '/OU rT1Ijsl ~ lamdmr WIth !he elfecls of aIpt\a Of bela feeef)tor stJmulabon or bloclt. Tnc tn05t impott;itll ones 10 remembet are:

,.J Alpha- t fe~ Sllffiul.lion: vaso1!!l rapid ~(1011 of f)CtepWlepl'lline from ;!(Y COOte jw.t C/larI9f1 the artJQ and use some of me satrtc!' aefil'liZioos' &ti!1ley are tJici-y, s:irn:.. :hey tflinIr ycu lIIJ#~Ci(! reactfng tile OJ)(iQr!s, $C-e '1alse' trat'~, and :1,J11"of) at optIOn (d). and flO( NtIKf ~ Ie SH that wpiic:: Ie} is tile corrta in its name. you CCi/iC'ivSf n~T ;/")e Q:..;eSi:OfJ j':..,"--.",n to ~p1:0ns (bJ a)~:d ;'~J S;.;: yo\.' S!1.'f hav~ fa itJ1C)1.

Pa,1vnSDff:; i$ Ow IIJ iL Al11_ tllUs (a) an';! 2. a.re W'!tV;'1/, P/}ft/loxybenzamille is an alpl"rbIOc/lIU. I:Iut curare is if mcetinic receptor 010

Prepared oyM.LllH)rnpson, Ph. D., Dtrt. of Gcncral Dentistry, Tufl:s Denta! School

16. Whivh of \he following is NOT an adion of epinephrine. when adminislered intf3v~nouslyin a high dose?

a Increases liver glycogenolysis

...,.(is:, Causesbtonchiolar conslridlon

Y Produces a rise in blood p!eSSUfe

ct. Evokp.s extras),5toles in the heart

e Produces resUesSI1ess and anlderl

(bja/l of lhe above are aclions a/epinephrine except bronchiolar con$lriction. Epinephrine woiJ/d cavse broll/modi/ation - /hat js why it is used to treel acute brochospssm. So option (b) has to be the exception, because It .is juSl obviously wrong!

ii Epinephrine reversar of blood pressure can oosl be demonstrated by injecting epinephnne intravenously after

r treatment with ~CI. PraZosin . Atropine

c. Propranolol d. Neostigmine

tl. Isoproterenol

_ (a,! epinephrine is a potent stimuiaIDr 0/ both alpha Ilnd .bela receptors. Injection of epi USII1JIIy causes a rise in blood pressure due to I) myocardfal stirrlcJI4/ion that increases ventricular contraction, 2) an meres$/! in flem me, and most important. 3) ~oconstricticn due 10 alpha receptor somuiation. However, blood tIow to slteletal muscles is increased due to poWfllful beta-2 receptor vasodl7ator aCUon that is only partially cOUnterbalanced by a vasocoostJictor action on the alpha receptors that are a/so preS6llt m the "asculIJr bed When gillen in Ihe presence of an alpha blocKftr. beta-IeCeplormelifliled vasodilation is more pronounced, the total peripheral TluJ.stance is decreased ana the mean bloodpres:stJre faUs. This decrease In bIoo

muscle of the peripheral vascuJatfre. whit;h i$ an aipha-1 stimulatory action. Of the options, (a), (c) andre} are aJpna-l agonists. Phentoalmine is a nonselec.tive alpha blocker and t.'IIiS would cause vasodilation. PfO{)ranctof is a non-specitic beta-Necker.

24. Carb/dopa. a dO~e

;'tepared by M.L Thompson, Ph. D, Dept. of General Dentistry, Tufts Dental School

highest a. Affinity I). Potency

'\lj i 11f.J(t~':; liw/'s wny they .ue ,Jio;;yr.crafic - :n.. Ii tfw;;! "{),,,,' {ii' roti,!e6 oy 8fJ}ttI~

14 Two ~rogs, A lind t:l. hav" lili! same mtO'\a!'1.l$ffi Qf aJ aqonislS and :mtas/cHlSlS oc:::t.:n It'" same receptO' lute, MI t;tledtire aolagQrust sh:;(,.lOf';a1 10 !lH~

numbef of r~eptDro occupied e. (1 follo..O$ tilt' law of mass actlOl'

17, * occupatiol141i theory of dl"f.l1d'receplo;' interaction stales Ina! "''C' W The magmtude of the drug responSJt is proportional to the

- number of receptors occupied b, A pMJaI agonisl has intrinsic aellvily but ne affinHy for tile " recelllof sitll

, -@ An ilIl~ist drug !'las affi.'lil) OUt 00 lnirinslG activit,

ct The rate :al wtltCillhe dnI9'fli~ceplOf complex asso

lll'p;ned by M.L 11lompson, Ph. D., Dept. ofGcncral Dcntisny, Tu.i't.!> Dental School

opt:fipneral wnex synapses Cttnkal GABAerglc neurons d. Cenlfal serotoncrgiC neurons c. Central adrenergic neNC endings

Ie) Answer is (e)- memorization BDZ's bind 10 silos on the GABA r8CE!ptOl'.

,\/1 allhe following pel1ain to general anesthesia induced by thiopental EXCEPT: j-,.. Fast induction \B;i Oe1:reased seerelions !J\ f L,~t..;. ,~ .' ,"" 'Y" p?-r .~

en low Cl1etapeu(ic index ~,'oj ,'-" -...'. - ~ d. Short duration.ofanes!hesia

e Predisposition to laryngospasm

ib} B8rbiturstes are problematic as aT1eslhelics because they often il!,duce excessi~'e salivation and bronci'liaJ secretion. usually requmng tile use of an antlchpJinergic drug to be administered 10 reduce Ihese sacretions. Thus (b) .'1as 10 be Ille false statement.

31 WhIch 01 !he following factors contributes \0 !he short durqtlon of action of a single dose of thiopental?

3. rapid biotransformation

b rapioaccumulatiOn in body tat

,~ high lipid solubility of the unOlSSociated form

.:_~ ability to enter and !eave the brain tissue rapIdly

(d) is correcl-Ihiopentalls the classic example always given of 8 dr.Jg whose durarion of action is determined by rggistoPuljosl away from its site of action in the brain (0 less WEill ;xirlusSd tissues. Tlu'Jy leave OUI the WQ(d redfslribution from the answer to .;onfuse you they know this is the way you learned it

5. Speed of recollery (rQrn short-acUng anesthesia with thiopental depends chiell)' on !he rapidity 0/

a. Renal tubular sO'etioo

b Hepatic degradation of !he thiopental group

(7:!"'1"fedistribution (rorn the brain 10 skeletal muscle

Y-Rellersediffuslonaeross the blood-br:3in barrier

e. None of the above

(e)

5 7he action of the ultrashort-acting barbiturates is terminated primarily by the process of

Xjdauon ~edlslributionb '. enal excreUon

cJ Plasma protein binding

e Conjugation with sulfate

Ib)

7 Wt'llch 01 the following is NOT charac!er~~tic of barbiturates? ~ Possess anticonvulsant properties

{,3[, (~} ant;:! {d1

(di:;nd (O! Otliy

P.r, "Cl;Jntl {C}

"'; {tl~:ni}

{iJ Am,.et ,.lI {aj- '(j" is 1;'111 iibwwe co"l1iIinrJic;tJtioll for v",tDi1Uf8ta lise. smce mese dn..'gS s:i~ th& synthesis (If /1

~iW4>e lJlu c:liseou;e Thus t'1e answt"lr !TlLI$1' CM1ain "ct'. etl/"t!ll!aiifl!) (e} and {d}. Sir,ce: 1xJi!: to} and {b} differ 00.1)1 by i#temahve c. 11Ia( IS me SiJO)Jld la(Cj updated versiOn 01 this qtJestion: might 4"$;) ,";a]opef1{1pi irste!1d 01 pheno(hiazir1:es

~. The antip$~Il(; elf~ts of pnenolhiaz.>neS rault ire'!> 3. Release of serotonin In Ihe bQin

" ' . ~ Rele.l:lc of nOfl:p!llt:plltlne In ttle br.;in -"',;:,'c\ 'ai~ of dopamil\efgil; sites In the bfa.'1

"~>Ar. iOCfe2Se in tne dopamiIIecontel'l! 01 :he :er!tr:alCO

Ir~PlJn:d by MI .. Thumpson, Ph. D .. o.,pt of Genml Dpnli~ry, Tufts Dental Schoul - ,C.;.' .t~ i

4. Chlo;prQrna::.in~ and relaled drugs are trlOlJght al act by bIoc!Iing whiCtl of the following receptors? a. Aareneroic b .Muscarinic

.1fJDopaminergic

"0; CenlIal serotonin

ie) Answer is (c)- ChJOfPI'MIszine is the prototypic pnenOlhi6zine. qn antipsychotic drug used in /he treatment of schizophrenia. Other antipsychotic drugs.ussd for /his purpose ere haloperidol and lhioridazine. These dn.tgS act via dopammergic receptors.

Side Effects

5 VVhlcn 01 Ille following is an ineversible side- e!l.ec! resulting from !ong-term adminislration of phenolhlazineS?

a. Sedation b. Xerostomia c. Inlertllity ..d_. ParkinsoniSm

-If'\' Tardive cysl

" HypelgfyClil'f'i.a

'''c:.lM)'OCOlfdia} alrophy

t'. RoolSlribution of booy fat

(ei}

4, GIU~terold$ are useful as seccf'lC;)f'y !;talmil

inflamf118lory proc.ess. - thus (d) is the correct answer. Tn!! olher alternatives ate single steps along the pathway. that are handled by allier drugs thaI are more selective than glucocorticoids,

Adrenal steroids are u~d successfully 10 Ireal an 01 the following

COflt!)n~~~~~~s (j)'.f~L\ '. }) \~)J)J ) b_ Addison disease .. _J_ \ \ C. Lupus erythematosus ct. RheumatoiO arthritis

Aphthous stomatitis

(ill adrenal steroids. olhfilFWise known as corticostemids, actually cause gastric ulcerstAllthe resl are Ulerapeutic uses,

General Anesthetics:

Ouestions always come up regarctlng factors that influence the rale ot inductlon_ Remember thaI onset of anesthesia is inversely OfOpor1ional to solubility 01 !he anesthetic. in the blood. The more SOluble !he agent is in blOOd. !he mom must be given to reach critical tension In the brnin.

2 A seCOnd set of questions has 10 do WIth adverse side effects of various general anesthetics. Halothane Is associated with hepa lotoxici ty. '7

3. Some questions are based on !he progressive depression of eNS function leading to anesthesia thaI characle!ized older anesthetic agents. Remember \he 4 stages of anesthesia:

Stage I: analgesia /.,Slage II: delirium , '~.Stage III: surgical anesthesia ,,-.( Slage IV: medullary paralysis

Frequently asked questions;

1 Signs and stages of anesthesia are most likely to be seen wi1l1 a general anesthetic thai has a

a Low potencyC@J, Slow rale of induction '~' Low Ostwald coefficient

d. HIgh oil'''''3ler SOlubility wetficienl e. High tissue-blood partition coeffiCient

(0)

4 AI! of the following influence the rale ot induction during anesthesia EXCEPT.

3, Pulmonary v~ntilatlon b Blood supply to the lungs ~ Hemoolobin content of lhe bloodY CA:mce';,trallon of 1I1e anesthetic in the inspired mixture

e. Solubility of the an~thelic in blood (blood-gas partition coetiicient. Ostwald

f~!tQr: OICC.~~f s;,..;'ClJ Q$ :'a:are~ l!u;s (b) an.J (d) are ~\'rrx:g. =~

.7!fVlli ;onfU3iJ )'OU A/mplIle is used to OitCfn4e v8gi';jj act'vlt).

e~t ti'r-at r5 n0( the f~hiSOfJ rt is g1\'EUl be/o,re haictnarU!,

Antihistamines:

5. VVhn:n of the fOUry..itng an~filst.arJljnes is. most commonly usedd"e5ucr.s mQ3roinu antihIstamines generaU} ,",,,nl ~'OO to know whal . preoperative meCIC31l0n',H 1 and H2 antlhis ,a01ines alll IJSed for il. Medlzine

.Jl Cydlzine ~Prtmeltlazine

Q. OIrnetIIl>drinale

T.a:em1~ rTlaPiff:SjaliCl'lS 01 ill! illl;lgtSi fMponu Cl1laph~ee.

( ~~h;1I1~ I .

Preoveralive medication to( ~ed I 1. anUemetlc ro ertip.s.

Prep:ueO by M.L. ThomPlon. Ph. D, Dept. ofGeneral Dentilltt)', Tufu Demal School

24. Which of the fo/fowing drugs is otten used to treat IJigeminai neuralgia?

&. dooazepam /~rbamazepine

~celiJ;1.o!amine dSUo;;QoylChaiine

An~w(J( is (b)- This i.s a memorization question. CarbomslRpme. a$ wtj// as phenytoin, are tIkt main dllJgS used to treaf trigeminal neuralgia. CIonazspam is a beflzodit1Hpine, succinylcWme is a dspoIarizing neuromuscular bkJckil'lf1 agent, while acetBtolamine is an anticonvulsant/ike carbamazepine.

1. The use of epinephrine for local hemOstasis dtJring surgery might resull in

. an1hymia; hypoQlyQmlla'-e" -.... .1In acute ;l$thma attack o. a drastic dlop in blood pres.suAI e. any of !he above

The 8f1Swer is (b). cardiac amhymias are . bad . e eH~t of e . s ,. Epi stimul BS bot/)

and beta TflCeplOI$. Seta ~ ate found in the heart and stimu/aUon a/beta /'II1!8pI.OI$ inc:n:~s head rate, force ofcontraction, cslViac O/ItpUt Mdoxygen utUizalion. (iI) 1$ wrong, epi elevates blood g{uaJH. (c) is Wf'OI19" bela stimulation in smooth muscle and bronchi causeS bronchodilaJion, and is thus a drug ofchoke for K'Jle asthmatic atl.acJcs. (d) is .obviously wtOng.. a decrease ill brooe! pressure WOUld not rewll from adlallfWJiC stimulatiOn. mcreased bfoocJ pressure is the rule.

4. The highest risk 3$Sociated with use of oral contraceptives is il. hepaUc neaosis b. permanent sterility c. C8llcef of tile breast ~. cancer of the uterus

~"c:rromboemba"'c disorder.s

The two major side effects are suspected carcinogenicity and the tentirmcy to prodUce tl!rpmb$l!tnlJoIIsms. Liver function call be altered bUI this ;s reven:iblfl. Rtfsesrch has failed to prove the link betwesIl estrogen and breil$t cancer; and raprocJuctlve function ivetitLiaHY'retlJlN upon cessalion of therapy. The answer accorrflll9 to the gods of Ihe testing board is (e). Amen.

#9. F~ common 10 all forms of drug

c.. waflannphenylt:uiaLOfle d. carbon rtlQw,;"tde-t,t e!ters or iJl'nirJes All c:f tI1e othel' altematIyes diverge W!

Prepared by M.L. Thompson, Ph.. D.. Dept. of General Dentistry, Tufts Dental S~hool

secretion ((e)) In cases of paptlc ulcer, Thi$ is its only clinical use, You might see It In aquesoon regarding drug merabolfsm, it is alSO 8 potent inhibitor of/he mixoo function V)(ldase dmg mo/abWiling en1}'me syst~m in lhe /lvQ(. Thli' other alternarives iJre to confusc you bec4useyou prOb()oly at iflasl remember (hal it is an antihistamine, but you 00111 Kmw the dif1~rencc between N1 8M H2 antihistamines.

55. vVhich of the following anticancer drugs can be dassified as an antimelabol.te?

a. dsplatin b. lomustlne c, vincristine

- "(~,nethotrexate

, -,....

Answeris (d) , I would guess (d) because its tIle only one I'lie everheard of. and since this wasnl covered in class yOU lTI/ghl be one 10 guess it alMi. Wow, we gol itrigllt! Actually, it you look the others up, (a) & (b) are alkylating agents, (e} is an alkaloid t:kri~"ed from plants. (d) is a folBte antagonist, Which acts 8S an antimetabolite. Just for your future edifICation, most cancer chemothttrapy drugs cause cell death byalfecting the ablTJty of cells 10 divide. The drugs thus in/libJ/ one or more phases of the ceO cycle or prevent a cef( in Go (/flfI nondividing phase) from entering1mo thecycie of ceU division. Anlimelabolite.s may act in 2 ways (1) by illct;lf'pOfalion into a metabolic pathway and forma/ion of a false metabolite which is nOllfunctionai or (ZJ by inhibition of the catalytic function of an enzyme or sMyrne system, Metholrexate is an example of a ceH cycle specific antimetabQilte that inhibits DNA synthesis during the S ph8$.e. Vincristine acts during the mitotic phase

66, Which o(!he following hormones acts to elevate blood concentration of ionic calcium? a. glucagon

; --'l!i:\Oara tilyroid ~~dO$tefOl1e d thyrotropin e, thyrocalcitonin

Answer is (b)- maintaining U1e concentration of CaH in extracellular auid by regulating the deposition and mobilization of calcium from bone, ab.socptiQO from the 01 tract, ElXCfetion etc, Is the main function of parathyroid hormone. Thyrocalcitonin is another name for calcitonin. They hope to confuse you because there Is a correlation between calcitonin and calcilJm, except that calcium concentrations regulate the synthesis and release of calcitonin. Glucagon is a pancreatic hormone that sllmulates glucose production. thyrolr.opin is there 10 contuse you with parathyroid hormone, and aldosterone regulates Na+ level.s not Ca++,

57 D,sorientation, confusion. and hallucinatiOns resulting from an overdose of scopolamine are most efficaciously treated by admlnisterfng ph;~;::k;l'n'("'.'i1

~rcp;ua aSpirin

.. cortisol ~laminy

Ia' Dracycardia IS J retle,.ive siowea heart rale. cen/roi/ed I>y ,,,,gal input to :he 11031f, and t$ ctJoIinergicalJy rr.edfatec, 11;1uc.!l rrleMS 1'0li .'1ii'eo J choJineflijic: reli.~.=l.Ie 3r:C are SIi1)jftCt 10 more f'8:(:id e.rc:relicn

ie} (Jf!

Prepart'd by M.L Thompwn. Ph. D., Dept. of GC1IeraJ Dentist!)', Tuits ~nr:,1 School

ft:)edation and ability to produce dej)endence

'1r'amnesia and sk.eletal muscle relaxation

(el tnt: only definition which covers iJiI me drugs. (8) applies only to pentOlJarbilBf. (b) applies ollfy to meperidine, and (d) applies only to diazepam.

15~. The onset of action of a drlJ9 is primarily determined by the rale .)1 .' ~.excrei10n

'; bsorplion

" . distribution

d biotransformation

fbi Obviously. drtJg has to Oe absortJed before any of the other 3ctions can tal

d, phenoxyOtloZamifle and OJ!ar~ " ;;mptletamme;mll propranolol

fe,' ,;; sympatl)omtnJelic drug/! going to polentialfy activate Octfl alpha ana ~ta rer;~Qf's. $0 .yc~ wouki '1eed iJ paiti(lg :;:l Clugs wM:JI aIocIIs tflOse f869 E"en olltll!: IlJlkr...mg tS a COO'\fTlOI'I side elled 01 prolonge3. dlarmaa

Ii ~uperin~cticn

c phloseosHlv,ty ~ visual dlstlJft)ance ,

-"T' discclorallon or !'Ie\\1y t(Jfmmg leeth

(OJ ~mce you use tetracycline everyday. you have commi1tefi aU tt~IS $tuff to memory, right? I would hope, since hardly anyone outside peFiodonfists hardly uses tetracycfints .mymore in dentistry that they would nof ii/Sk you 1/ lot of questions a/)out tetracyclines. but If tlley do, you'r. relldy, right?

',0 To redu,;e a palient's salivary flOW, a dentist has prescribed atropine As a result of lI1is medication, Itle patient might

e~perier1ce which of the following side effects? o. sedaUon

,VI :;'causc tI Will 8i$O cal.a. agonism o. potency .~ffica.cy V.sp&cifidty te) effJ,Q1CY $OUf'n-:i.s like it migrt !!3\"C ~~c~(j'lrl~ tc l!Q ~~,~f!

effect.. doesntit?..Didnt! maxe yeu ~7JOri:e tcre!l~:~';'! etfic8r-:y' Po!9cflCY is how '1luch dn.'f, dces it :aM'f r,' prcd:.-ce an el!~-c.t. 8r:

P'.-p;lI .. d by M L Toompson. Ph. D. Dept of Gtner.ll Dentistry. Tulis Dental S-:hoo!

1&'! WI1idI 01 :he following agents found In Iobacro proouC's cause JddJCtIOO?

il to'lr orrnaldehYdc

.'~.' Itotine

. . camQn monoxid~

ee) if you are adc:licied to fotrnaldehyde. you afe dead! Same with the OrMrs. How dumb do they thinll you guys are?

'":'ll

d.. prozosin (Mlnlpress) b. prilocaine-tetracaine ... Clonid.ine (ca.tapress)

f(~ c atenolol (Tenormin)

. hydralazine (Aprezotine)

e. verapamil (Calan) (c) Illis is one of those questions where they give you five

drugs. as possible answers, and can create .5 different questions just by changing the queslion regarding mechanism of action. So (a) is an alpha' blockftf, (b) aipha-2 agonist thaI decreases sympathetic outfloefram eNS, (d) is a direct acting vasodilator. and (ej is a type I cafcium channel bIock.er

50. In which of the following categories are ephedrine. tyrOJmine. and amphetamine classified?

;;l..'4-.( ~.. '-' i

(e) memorize this picky fiN/e fact please!

110. Each of the following is a pharmacologic effect 01 phenothl3z,oes EXCEPT one. Which one is the EXCEPTiON?

a.sedatlon b. an antiemetic effect c. alpha-adrener9ic etted d. potentiation of the action of narcotics(Vm anticonvulsant Ie) see, Iheyda ask you qUstionssbOl.lt drugs thaI you coni

normally use everyday. ACUons a, C, and d are all cJinic;Jlly useful actions 01 the phencthiazine$, which you mighl remember were discussed under l,~e category 01 antipsychotic drugs. But wait Promethazjne (PheflCl\liln) is used in dentistrl a.s a sedative, often in combll1ation with Demeral because it reduces the nausea associated with Ihe use of the opioid and a/so polenliates ifs analgesic effect, e/lowing lower dose 10 be used, Ihu~ again reducing the potential for adverse side effects. Alpha adrenergic effects are an adverse side effect.

119. Epinephrine antagonizes the effects of histamine by a. prevenUng the release of histamine

--C:1.. ~acting on the central nervous system ---:::;::r- educing physiologic actions opposite to that or histamine

. competitively blocking histamine at the cellular receptor~it

(c) exactly why I kept asking you on every exam to gIVe IT'.e.an example ofphysic10gjcal antagonism as a drugdrug interaction Question. It does not act lI;a (a), ....,hich IS how cromolyn (/ntal) works, or by (d) which is how antillistamines work.

121. Which of the following represents the drug-or.choice in the treatment of candidiasis for an HIV.infected patient? r-:Ncydovir

~ystatJn c.AZT d. chlorhexidine

tb) candidiasis is a fungal infection that neeCls 10 be trea/eO with an antifungal agent like nystatin. (ilj and (c) are antiviral drugs used to treat HIV, while chiorne:.

~parcd by i\U.. 'I11ompson, Ph, D., Dept ofGeneral DcntJstry. Tufts Otntal $.hoQi

2 A patient presenlS fOI treatment 01 a large fluctuant mass in the submatKjibular spaCD as a result of extension of odootooenic infection. He has a temperature of 35.5 degrEes C (101 "degrees Fl Initially, the dentist should treat this patient with which of the following?

a. salicylale therapy to reduCll the temperature b. altemale application 01 heal and cold to the area to improve

Circulation mjncision and drainage and. a culture forantibioUc sensilJ...ily

-"it-anlibiotic therapy to reduce thesweiling and infection

(e! anlibioticlherapy wonl be very &ffective jf you donl indse and drain first. la) and (b) are palliative actions the patient can lake alhome, nol adiom for the dentist.

46. The only local anesthetic that increases the pressOf activity of .--!>W eptnephrine and 'lCrlWinephrine is

. n::tcocaine "'~\iJ"u. procalOe C. dibucaine d. lidocaine

E mepivacalne

(a) My, wily do they always ask some dumb question like this about COCaine-like you guys use it evel}' day in your office (you belter no!!!). Any lVay. remember, cocaine is an indirect acting adrenergic ~nisl, acting by causing the release of adrenefQic neurotransmitters as well as blocking I~jr rovplake, thereby prolonging their activity. The other qrugs listed are justJoca: anesthetics thai don't have /his;lclion - they just block sodium influx into the neuron.

155 Corticosteroid therapy for arthfilis is contraindicated for a patient wno also has which of the fOllOWing conditions?

it anemia b. nephritis

alco/1oliSm d. :peplic ulcer

__ rheumatic heart disease

~

rd.! patients using corticosteroids for arthritis often develop ulcers because these drug block prostaglandin aCfion in the stomach, thereby increasing acid secretion While decreasing the protective mucosal barrier of the ~I()l118ch.

160. WhIch 01 the following is the ti{~1 symptom illa! is usually perceived by the patient being administered nitrous oxide?

d. nause,a

I). eupl10lia

~ioctiness

. ~ogIfng 01 the hGods

,-.

{dJ/he firs/three are ali SigllS thai 1110 palien! is getlmg 100 much nitrous.

176. E3Ch of the following, EXCEPT one, is a good reascn tor using seoaliM. Which ooe is Ihis EXCEPnON?

~..;"10 ailay apprehension. anxiety Cif fedr

~c decrease the 8fTlO'.!nt of local anesthesia that is require

/. :,i

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