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Test Bank For Little and Falace's Dental Management of the Medically Compromised Patient, 9th Edition

Test Bank For Little and Falace's Dental Management of the Medically Compromised Patient, 9th Edition makes exam prep stress-free with clear explanations, revision notes, and test strategies.

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    1 Chapter 01: Patient Evaluation and Risk Assessment Little: Dental Management of the Medically Compromised Patient, 9th Edition MULTIPLE CHOICE 1. Elective dental care should be deferred for patients with severe, uncontrolled hypertension, meaning that the blood pressure is greater than or equal to ________ mm Hg. a. 200/140 b. 180/140 c. 180/110 d. 160/110 ANS: C Elective dental care should be deferred for patients with severe, uncontrolled hypertension, which is blood pressure greater than or equal to 180/110 mm Hg, until the condition can be brought under control. 2. The American Heart Association currently recommends antibiotic prophylaxis for a patient with which of the following cardiac conditions? a. Mitral valve prolapse b. Prosthetic heart valve c. Rheumatic heart disease d. Pacemakers for cardiac arrhythmias ANS: B Previously, the American Heart Association (AHA) recommended antibiotic prophylaxis for many patients with heart murmurs caused by valvular disease (e.g., mitral valve prolapse, rheumatic heart disease) in an effort to prevent infective endocarditis; however, current guidelines omit this recommendation on the basis of accumulated scientific evidence. If a murmur is due to certain specific cardiac conditions (e.g., previous endocarditis, prosthetic heart valve, complex congenital cyanotic heart disease), the AHA continues to recommend antibiotic prophylaxis for most dental procedures. 3. One consequence of chronic hepatitis (B or C) or cirrhosis of the liver is decreased ability of the body to _________ certain drugs, including local anesthetics and analgesics. a. absorb b. distribute c. metabolize d. excrete ANS: C Patients also may have chronic hepatitis (B or C) or cirrhosis, with impairment of liver function. This deficit may result in prolonged bleeding and less efficient metabolism of certain drugs, including local anesthetics and analgesics. 4. Which of the following symptoms and signs is most consistent with allergy? a. Heart palpitations b. Itching c. Vomiting d. Fainting ANS: B Symptoms and signs consistent with allergy include itching, urticaria (hives), rash, swelling, wheezing, angioedema, runny nose, and tearing eyes. Isolated signs and symptoms such as nausea, vomiting, heart palpitations, and fainting generally are not of an allergic origin but rather are manifestations of drug intolerance, adverse side effects, or psychogenic reactions. 5. Which of the following is true of the patient with a history of tuberculosis? a. A positive result on skin testing means that the person has active TB. b. Most patients who become positive skin testers develop active disease. c. Patients with acquired immunodeficiency syndrome (AIDS) have a high incidence of tuberculosis. d. A diagnosis of active TB is made by a purified protein derivative (PPD) skin test. ANS: C The potential coexistence of tuberculosis and acquired immunodeficiency syndrome (AIDS) should be explored because patients with AIDS have a high incidence of tuberculosis. A positive result on skin testing means specifically that the person has at some time been infected with TB, not necessarily that active disease is present. Most patients who become positive skin testers do not develop active disease. A diagnosis of active TB is made by chest x-ray, imaging, sputum culture, and clinical examination. 6. Vasoconstrictors should be avoided in patients who cocaine or methamphetamine users because these agents may precipitate _________. a. severe hypotension b. severe hypertension c. respiratory depression d. cessation of intestinal peristalsis ANS: B Vasoconstrictors should be avoided in patients who are cocaine or methamphetamine users because the combination may precipitate arrhythmias, MI, or severe hypertension.

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    2 7. It has been shown that the risk for occurrence of a serious perioperative cardiovascular event (e.g., MI, heart failure) is increased in patients who are unable to meet a __-MET (metabolic equivalent of task) demand during normal daily activity. a. 4 b. 6 c. 8 d. 10 ANS: A Daily activities requiring 4 METs include level walking at 4 miles/hour or climbing a flight of stairs. Activities requiring greater than 10 METs include swimming and singles tennis. An exercise capacity of 10 to 13 METs indicates excellent physical conditioning. 8. Which of the following alterations in the fingernails is associated with cirrhosis? a. Yellowing b. Clubbing c. White discoloration d. Splinter hemorrhages ANS: C Alterations in the fingernails, such as clubbing (seen in cardiopulmonary insufficiency), white discoloration (seen in cirrhosis), yellowing (from malignancy), and splinter hemorrhages (from infective endocarditis) usually are caused by chronic disorders. 9. A blood pressure cuff should be placed on the upper arm and inflated until _________. a. the radial pulse disappears b. the radial pulse disappears and then inflated an additional 20 to 30 mm Hg c. two fingers cannot fit comfortably under the cuff d. the pulse no longer can be heard with the stethoscope ANS: B While the radial pulse is palpated, the cuff is inflated until the radial pulse disappears (approximate systolic pressure); it is then inflated an additional 20 to 30 mm Hg. 10. Which of the following is true of a patient classified ASA III according to the American Society of Anesthesiologists (ASA) Physical Status Classification System? a. Patient has mild systemic disease. b. Patient’s disease has significant impact on daily activity. c. Patient’s disease is unlikely to have impact on anesthesia and surgery. d. Patient is moribund. ANS: B Patient with severe systemic disease is a constant threat to life (e.g., recent myocardial infarction, stroke, transient ischemic attach [<3 months], ongoing cardiac ischemia, severe valve dysfunction, respiratory failure requiring mechanical ventilation). Serious limitation of daily activity; likely major impact on anesthesia and surgery.

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    1 Chapter 02: Infective Endocarditis Little: Dental Management of the Medically Compromised Patient, 9th Edition MULTIPLE CHOICE 1. Which of the following is true concerning infective endocarditis (IE)? a. IE is always due to a bacterial infection. b. Since the advent of antibiotics, morbidity and mortality associated with IE have been virtually eliminated. c. IE is currently classified as acute or subacute, to reflect the rapidity of onset and duration. d. Accumulating evidence questions the validity of antibiotic prophylaxis in an attempt to prevent IE prior to certain invasive dental procedures. ANS: D Antibiotics have been administered before certain invasive dental procedures in an attempt to prevent infection. Of note, however, the effectiveness of such prophylaxis in humans has never been substantiated, and accumulating evidence more and more questions the validity of this practice. 2. Which of the following is currently the most common underlying condition predisposing to infective endocarditis (IE)? a. Aortic valve disease b. Rheumatic heart disease (RHD) c. Mitral valve prolapse (MVP) d. Tetralogy of Fallot ANS: C Mitral valve prolapse, which accounts for 25% to 30% of adult cases of native valve endocarditis (NVE), is now the most common underlying condition among patients who acquire IE. Previously, rheumatic heart disease (RHD) was the most common condition predisposing to endocarditis. In developed countries, however, the frequency of RHD has markedly declined over the past several decades. 3. The leading cause of death due to infective endocarditis (IE) is __________. a. chronic obstructive pulmonary disease b. heart failure c. pulmonary emboli d. atheromas ANS: B The most common complication of IE, and the leading cause of death, is heart failure, which results from severe valvular dysfunction. This pathologic process most commonly begins as a problem with aortic valve involvement, followed by mitral and then tricuspid valve infection. Embolization of vegetation fragments often leads to further complications, such as stroke. Myocardial infarction can occur as the result of embolism of the coronary arteries, and distal emboli can produce peripheral metastatic abscesses. 4. The interval between the presumed initiating bacteremia and the onset of symptoms of infective endocarditis (IE) is estimated to be less than __________ in more than 80% of patients with IE. a. 1 week b. 2 weeks c. 1 month d. 2 months ANS: B It is less than two weeks in more than 80% of patients with IE. In many cases of IE that have been purported to be due to dentally induced bacteremia, the interval between the dental appointment and the diagnosis of IE has been much longer than 2 weeks (sometimes months), so it is very unlikely that the initiating bacteremia was associated with dental treatment. 5. Where are Janeway lesions located? a. Tricuspid valve b. Palms of the hands and soles of the feet c. Pulp of the digits d. Nail beds ANS: B Janeway lesions are small, nontender erythematous or hemorrhagic macular lesions on the palms and soles. Janeway lesions are one of the peripheral manifestations of IE due to emboli and/or immunologic responses.

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    2 6. Which of the following is true of the magnitude of bacteremia required to cause infective endocarditis (IE)? a. The magnitude of bacteremias resulting from dental procedures is more likely to cause IE than that seen with bacteremias resulting from normal daily activities. b. Cases of IE caused by oral bacteria probably result from frequent exposure to low inocula of bacteria in the bloodstream due to daily activities and not a dental procedure. c. The quality of oral hygiene has no appreciable effect on the magnitude of bacteremia after toothbrushing. d. The magnitude of bacteremia resulting from dental procedures is greater than that needed to cause experimental bacterial endocarditis (BE) in animals. ANS: B An assumption often made is that the magnitude of bacteremias resulting from dental procedures is more likely to cause IE than that seen with bacteremias resulting from normal daily activities. Published data do not support this contention. Furthermore, the magnitude of bacteremia resulting from dental procedures is relatively low (with bacterial counts of fewer than 10 4 colony-forming units/mL), is similar to that of bacteremia resulting from normal daily activities, and is far less than that (10 6 to 10 8 colony-forming units/mL) needed to cause experimental BE in animals. 7. Visible bleeding during a dental procedure is a reliable predictor of bacteremia. It is not clear which dental procedures are more or less likely to cause transient bacteremia or to result in a greater magnitude of bacteremia than that caused by routine daily activities such as chewing food, tooth brushing, or flossing. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false. d. The first statement is false, the second statement is true. ANS: D It has been shown that visible bleeding during a dental procedure is not a reliable predictor of bacteremia. Collective published data suggest that the vast majority of dental office visits result in some degree of bacteremia, and that it is not clear which dental procedures are more or less likely to cause transient bacteremia or to result in a greater magnitude of bacteremia than that caused by bacteremia produced by routine daily activities such as chewing food, tooth brushing, or flossing. 8. Which of the following is true regarding the efficacy of antibiotic prophylaxis? a. Data show that a reduction in the incidence, nature, and duration of bacteria caused by antibiotic therapy reduces the risk of or prevents IE. b. Antibiotics given to at-risk patients before a dental procedure will prevent or reduce a bacteremia. c. Prospective randomized, placebo-controlled trials have been conducted to examine the efficacy of antibiotic prophylaxis for preventing IE in patients who undergo a dental procedure. d. Investigators have concluded that dental or other procedures probably only caused a small fraction of cases of IE, and that prophylaxis would prevent only a small number of cases, even if it were 100% effective. ANS: D This conclusion came as the result of a study from the Netherlands by van der Meer and colleagues that investigated the efficacy of antibiotic prophylaxis in preventing IE in dental patients with native or prosthetic cardiac valves. 9. The American Heart Association currently recommends antibiotic prophylaxis before dental treatment to prevent endocarditis for patients with which of the following cardiac conditions? a. Mitral valve prolapse with regurgitation b. Rheumatic heart disease c. Prosthetic cardiac valve d. A, B, and C e. A and C ANS: C Prophylaxis with antibiotics before a dental procedure is recommended for a prosthetic cardiac valve, previous infective endocarditis, and some forms of congenital heart disease (see Box 2-2.) 10. Which of the following antibiotics is the best choice if a patient who requires premedication before dental treatment is already taking penicillin for eradication of an infection? a. Amoxicillin b. Clindamycin c. Cephalosporins d. Keep the patient on the penicillin because the blood level has already been achieved ANS: B The presence of viridians group streptococci that are relatively resistant to penicillin or amoxicillin is likely in pat ients already taking penicillin or amoxicillin for eradication of an infection. Clindamycin, azithromycin, or clarithromycin should be selected for prophylaxis if treatment is immediately necessary. Cephalosporins should be avoided due to cross resistance. Another approach is to wait for at least 10 days after the completion of antibiotic therapy before administration of prophylactic antibiotics.

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    1 Chapter 03: Hypertension Little: Dental Management of the Medically Compromised Patient, 9th Edition MULTIPLE CHOICE 1. In prehypertension, diastolic pressure ranges from ________ mm Hg. a. 80 to 89 b. 90 to 99 c. 100 to 109 d. 110 to 119 ANS: A In adults, a sustained systolic blood pressure of 140 mm Hg or greater and/or a sustained diastolic blood pressure of 90 mm Hg or greater is defined as hypertension. (Also see Table 3-1.) 2. Which of the following types of health professionals can make the diagnosis of hypertension and decide on its treatment? a. Physician b. Dentist c. Dental hygienist d. A, B, and C e. A and C only ANS: A Although only a physician can make the diagnosis of hypertension and decide on its treatment, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) guidelines specifically encourage the active participation of all health care professionals in the detection of hypertension and the surveillance of treatment compliance. Accordingly, the dental health professional can play a significant role in the detection and control of hypertension and may well be the first to detect a patient with an elevation in blood pressure or with symptoms of hypertensive disease. 3. Which of the following is true about hypertension in America? a. It is the second-most primary diagnosis behind congestive heart failure. b. Its prevalence has been steadily increasing 1990. c. Its prevalence is similar among all races and ethnicities. d. Its prevalence is similar among men and women. ANS: D According to National Health and Nutrition Examination Survey (NHANES) data for the period 2011 to 2012, at least 75 million adults in the United States have high blood pressure or are taking antihypertensive medication. This estimate equals about 29% of the U.S. population, compared with 24% when surveyed between 1988 and 1991. This marked increase is attributed to aging of the population and the epidemic increase in obesity. Accordingly, a typical practice population of 2000 patients will have about 580 patients who have hypertension. 4. It is estimated that about __% of all blood pressure–related deaths from coronary heart disease occur in persons with blood pressure in the prehypertensive range. a. less than 1 b. 5 c. 15 d. 25 ANS: C About 15%. However, the higher the blood pressure, the greater the chances of heart attack, heart failure, stroke, and kidney disease. For every increase in blood pressure of 20 mm Hg systolic and 10 mm Hg diastolic, a doubling of mortality related to ischemic heart disease and stroke occurs. 5. Which of the following groups is most often the first-line drug category of choice if lifestyle modification is ineffective at lowering blood pressure? a. Beta-blockers (BBs), α 1 -adrenergic blockers, central α 2 agonists, as well as other centrally acting drugs, and direct vasodilators b. Diuretics, thiazide diuretics, calcium channel blockers (CCBs), angiotensin receptor blockers, angiotensin-converting enzyme inhibitors (ACEIs) c. Any of the above. d. None of the above; lifestyle modification should continue unless blood pressure is >140/90 mm Hg ANS: B Many drugs are currently available to treat hypertension. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) recommends diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) as first-line choices for the general non-Black population. For the general Black population, a thiazide diuretic or CCB is recommended as initial therapy. Other drugs used as secondary choices include beta-blockers (BBs), α 1 -adrenergic blockers, central α 2 agonists, as well as other centrally acting drugs and direct vasodilators.

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    2 6. Deferral of elective dental care and referral to a physician for evaluation and treatment within 1 week are indicated for patients found to have asymptomatic blood pressure of greater than or equal to ________ mm Hg. a. 160/90 b. 160/110 c. 180/90 d. 180/110 ANS: D Patients with blood pressures less than 180/110 mm Hg can undergo any necessary dental treatment, both surgical and nonsurgical, with very little risk of an adverse outcome. For patients found to have asymptomatic blood pressure of 180/110 mm Hg or greater (uncontrolled hypertension), elective dental care should be deferred, and physician referral for evaluation and treatment within 1 week is indicated. Patients with uncontrolled blood pressure associated with symptoms such as headache, shortness of breath, or chest pain should be referred to a physician for immediate evaluation. 7. Which of the following is recommended for stress management for dental patients with hypertension? a. Afternoon appointments b. Premedication with a barbiturate c. Nitrous oxide plus oxygen for inhalation sedation d. Keeping the dental chair in an upright position during treatment ANS: C Nitrous oxide plus oxygen for inhalation sedation is an excellent intraoperative anxiolytic for use in patients with hypertension. Care is indicated to ensure adequate oxygenation at all times, avoiding postdiffusion hypoxia at the termination of administration. Short morning appointments seem best tolerated. Oral premedication with a short-acting benzodiazepine can reduce anxiety for many patients. Because many of the antihypertensive agents tend to produce orthostatic hypotension as a side effect, rapid changes in chair position during dental treatment should be avoided. 8. Why should rapid changes in chair position during dental treatment be avoided for patients under medication for hypertension? a. To lessen the chances of endogenous release of catecholamines. b. Alpha-blockers, alpha–beta-blockers, and diuretics tend to produce orthostatic hypotension as a side effect. c. Rapid chair position changes have nothing to do with antihypertensive medications and drugs used in dental practice. d. There is a high potential of triggering cardiovascular issues agents for hypertensive dental patients in moving chairs if local anesthetics are used. ANS: B Alpha-blockers, alpha–beta-blockers, and diuretics tend to produce orthostatic hypotension as a side effect, so rapid changes in chair position during dental treatment should be avoided. This effect can be potentiated by the actions of anxiolytic and sedative drugs. 9. Use of how many cartridges of 2% lidocaine with 1:100,000 epinephrine at one time is considered to have little clinical risk for dental treatment of a patient with hypertension? a. 2 b. 4 c. 6 d. 8 ANS: A The existing evidence indicates that use of modest doses (one or two cartridges of 2% lidocaine with 1:100,000 epinephrine) carries little clinical risk in patients with hypertension, the benefits of its use far outweighing any potential problems. Use of more than this amount at one time may be tolerated well enough but with increasing risk for adverse hemodynamic changes. 10. Which of the following is an adverse drug interaction that may occur if a dental anesthetic containing a vasoconstrictor is administered to a patient being treated for hypertension with a nonselective β -adrenergic blocking agent? a. Hypotension b. Hypertension c. Respiratory alkalosis d. Respiratory acidosis ANS: B The basis for concern with use of nonselective β -adrenergic blocking agents (e.g., propranolol) is that the normal compensatory vasodilation of skeletal muscle vasculature mediated by beta 2 receptors is inhibited by these drugs, and injection of epinephrine, levonordefrin, or any other pressor agent may result in uncompensated peripheral vasoconstriction because of unopposed stimulation of alpha 1 receptors. This vasoconstrictive effect could potentially cause a significant elevation in blood pressure and a compensatory bradycardia.

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    1 Chapter 04: Ischemic Heart Disease Little: Dental Management of the Medically Compromised Patient, 9th Edition MULTIPLE CHOICE 1. Which of the following is true concerning the incidence and prevalence of ischemic heart disease in the United States? a. About 50% of the population is estimated to have some form of cardiovascular disease. b. Cardiovascular disease begins in middle life. c. The annual mortality rate for cardiovascular diseases has been declining since 1970. d. Cancer has replaced coronary heart disease as the leading cause of death in the United States after age 65. ANS: C More than 85 million Americans (about 25% of the population) have some form of cardiovascular disease, with about 15.5 million having coronary heart disease. Cardiovascular disease begins early in life, and autopsy studies have shown that one in six American teenagers already has pathologic intimal thickening of the coronary arteries. The annual mortality rate for cardiovascular diseases as a group has been declining since 1970. Despite this decline, cardiovascular diseases continue to be the leading cause of death in America, accounting for about 31% of all deaths. Coronary heart disease is the leading cause of death in the United States after age 65, and it is responsible for 735,000 new or recurrent heart attacks annually, of which more than 40% are fatal. 2. Which of the following is the single MOST important modifiable risk factor for coronary heart disease? a. Diet high in cholesterol b. Failure to exercise c. Smoking cigarettes d. Smoking cigars ANS: C Cigarette smoking is the single most important modifiable risk factor for coronary heart disease. Multiple prospective studies have clearly documented that, compared with nonsmokers, persons who smoke 20 or more cigarettes daily have a two- to fourfold increase in coronary heart disease. This increased risk appears to be proportionate to the number of cigarettes smoked per day, and quitting has well documented benefits. Pipe and cigar smoking apparently convey minor risk for development of heart disease. 3. Which of the following is NOT true of the relationship between periodontal disease and cardiovascular disease? a. Studies report the possibility of an association between periodontal disease and cardiovascular disease. b. A single risk factor—dental caries—has been found to be responsible for the development of coronary atherosclerosis in patients over 50 years old. c. Studies indicate a connection between tooth scaling and a decreased risk of cardiovascular disease outcomes. d. There is a hypothesis that the chronic inflammatory burden of periodontal disease may lead to impaired functioning of the vascular endothelium. ANS: B Numerous studies have reported an association between periodontal disease and cardiovascular disease, raising the question of whether periodontal disease is a risk factor for cardiovascular disease. Although the mechanism to explain this relationship is unclear, it is hypothesized that the chronic inflammatory burden of periodontal disease may lead to impaired functioning of the vascular endothelium. At present, despite studies showing that tooth scaling is associated with decreased risk of cardiovascular disease outcomes and improved endothelial function, a direct relationship (i.e., causation) between periodontal disease and cardiovascular disease has not been established. Additional studies are required to further elucidate this relationship. 4. Which of the following types of blood cells engulf lipid molecules to become foam cells? a. Red blood cells b. Macrophages c. Neutrophils d. Basophils ANS: B Atheroma formation is initiated by adherence of monocytes to an area of injured or altered endothelium. The attached monocytes then migrate into the intima of the vessel and become macrophages. Lipids derived from LDLs also enter through the injured or dysfunctional endothelium, forming extracellular deposits or small pools. Macrophages then engulf lipid molecules to become foam cells, which are characteristic features of the fatty streak. 5. Which of the following is the important symptom of coronary atherosclerotic heart disease? a. Pitting edema b. Dysphagia c. Dyspnea d. Chest pain ANS: D Chest pain is the most important symptom of coronary atherosclerotic heart disease. The pain may be brief, as in angina pectoris resulting from temporary ischemia of the myocardium, or it may be prolonged, as in unstable angina or acute MI. Ischemic myocardial pain results from an imbalance between the oxygen supply and the oxygen demand of the muscle.

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    2 6. New-onset chest pain that increases in frequency or intensity has a changing pattern, may possibly occur at rest, and is not readily relieved by nitroglycerin. This best defines _________. a. acute coronary syndrome b. Prinzmetal’s variant angina c. unstable angina d. stable angina ANS: C Unstable angina is defined as new-onset pain with increasing frequency or intensity, and that is precipitated by less effort than before or that occurs at rest. This pain is not readily relieved by nitroglycerin. Stable angina is pain that is predictably reproducible, unchanging, and consistent over time. This pain is typically precipitated by physical effort, such as walking or climbing stairs, but also may occur with eating or stress. Pain is relieved by cessation of the precipitating activity, by rest, or with the use of nitroglycerin. Acute coronary syndrome describes a continuum of myocardial ischemia, and Prinzmetal’s variant angina is a relatively uncommon form of angina. 7. Which of the following is the most common cause of sudden cardiac death? a. Ventricular fibrillation b. Myocardial infarction c. Coronary atherosclerosis d. Pulmonary embolism ANS: A The most common cause of sudden cardiac death is ventricular fibrillation, a form of abnormal electrical activity resulting from interruption of the heart’s electrical conduction system. 8. Which of the following is a serum enzyme determination used to establish the diagnosis of acute myocardial infarction (MI) and to determine the extent of infarction? a. Stress thallium-201 perfusion scintigraphy b. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA) c. Troponin I and troponin T d. Streptokinase (SK) ANS: C Cardiac serum biomarkers of acute MI include troponin I, troponin T, creatine kinase isoenzyme (CK-MB), and myoglobin. The troponins and CK-MB are enzymes released only when cell death (infarction) or injury occurs. Troponins are proteins derived from the breakdown of myocardial sarcomeres. Troponin assays are the most sensitive and specific in differentiating cardiac muscle damage from trauma to skeletal muscle or other organs; and are virtually absent in the plasma of normal persons and are found only after cardiac injury. 9. Which of the following is true for an MI with ST segment elevation (STEMI)? a. It is due to partial blockage of coronary blood flow. b. It is due to complete blockage of coronary blood flow. c. Early fibrinolytic therapy will not improve the outcome for a patient with STEMI. d. Morphine use for pain relief is never recommended for STEMI patients. ANS: B An MI with ST segment elevation is due to complete blockage of coronary blood flow and more profound ischemia involving a relatively large area of myocardium. An MI without ST segment elevation (non-STEMI) is due to partial blockage of coronary blood flow. Early fibrinolytic therapy improves outcomes in STEMI but not in non-STEMI. Morphine use for pain relief is recommended for STEMI; however, use of morphine in non-STEMI patients is associated with increased mortality and should be avoided in these patients. 10. When planning dental treatment for a patient with stable angina or a past history of MI without ischemic symptoms, _________. a. administration of nitrous oxide should be avoided b. a pulse oximeter should be used c. nitroglycerin should be administered prophylactically d. NSAIDs should be avoided ANS: D In several studies, the use of NSAIDs in patients with previous MI has been shown to increase the risk for a subsequent myocardial infarction, even after only 7 days of NSAID administration. Only naproxen did not increase the risk.

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    1 Chapter 05: Cardiac Arrhythmias Little: Dental Management of the Medically Compromised Patient, 9th Edition MULTIPLE CHOICE 1. Which of the following is the most common type of persistent arrhythmia? a. Sinus arrhythmia b. Premature atrial complexes c. Atrial fibrillation d. Ventricular flutter and fibrillation ANS: C The most common type of persistent arrhythmia is atrial fibrillation (AF). AF affects more than 2.7 million people, and the majority is over age 60. In a dental practice of 2000 adults, one can expect about 300 patients to have some type of cardiac arrhythmia. 2. Which of the following sequences correctly depicts the normal pattern of sequential depolarization of the structures of the heart? (1) Right and left bundle branches, (2) sinoatrial (SA) node, (3) subendocardial Purkinje network, (4) bundle of His, (5) atrioventricular (AV) node. a. 5, 2, 4, 1, 3 b. 2, 5, 4, 1, 3 c. 2, 3, 4, 1, 5 d. 2, 5, 3, 1, 4 ANS: B The normal pattern of sequential depolarization involves the structures of the heart in the following order: sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, subendocardial Purkinje network. 3. Tachycardia in an adult is defined as a heart rate greater then ___ beats/min, with otherwise normal findings on the ECG. a. 100 b. 125 c. 150 d. 175 ANS: A Tachycardia in an adult is a heart rate greater than 100 beats/min. The rate usually is between 100 and 180 beats/min. This condition most often is a physiologic response to exercise, anxiety, stress, or emotion. Pathophysiologic causes include fever, hypertension, hypoxia, infection, anemia, hyperthyroidism, and heart failure. Drugs that may cause sinus tachycardia include atropine, epinephrine, alcohol, nicotine, and caffeine. 4. Which of the following is a disorder of repolarization? a. Mobitz type I (Wenckebach) b. Wolff-Parkinson-White syndrome c. Long QT syndrome d. Torsades de pointes ANS: C Long QT syndrome is a disorder of the conduction system in which the recharging of the heart during repolarization (i.e., the QT interval) is delayed. It is caused by a genetic mutation in myocardial ion channels and by certain drugs, or may be the result of a stroke. Mobitz type I (Wenckebach) is a form of second-degree heart block. Wolff-Parkinson-White syndrome is tachycardia involving the AV junction. Torsades de pointes is a variant of ventricular tachycardia. 5. What is a specific advantage of implantable cardioverter-defibrillators (ICDs) in contrast to pacemakers? a. ICDs generally are smaller than pacemakers. b. ICDs are capable of providing antitachycardia pacing (ATP) and ventricular bradycardia pacing, while pacemakers are not capable of providing such pacing. c. ICDs have batteries that last much longer than pacemakers. d. ICDs do not require antibiotic prophylaxis prior to dental treatment whereas pacemakers do. ANS: B ICDs are capable not only of delivering a shock but of providing antitachycardia pacing (ATP) and ventricular bradycardia pacing. ICDs generally are larger than pacemakers, and their batteries do not last as long as those of a pacemaker. 6. Recent studies suggest dental devices do not cause significant _________ with pacemakers and ICDs probably because of increased internal _________. a. interference; magnetic fields b. defibrillation; EMI c. cardiac arrhythmia; ATP d. EMI; shielding ANS: D Recent studies performed in humans together with previous data suggest that most dental devices do not cause significant electromagnetic interference with the sensing and pacing of pacemakers and ICDs. This probably reflects the increased internal shielding provided in the newer pacemakers and ICDs.

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    2 7. Which of the following is classified as a significant arrhythmia according to American College of Cardiology and American Heart Association guidelines? a. Pathologic Q waves b. Left bundle branch block c. High-grade AV block d. ST-T wave abnormalities ANS: C Patients with high-grade AV block, symptomatic ventricular arrhythmias in the presence of cardiovascular disease, and supraventricular arrhythmias with an uncontrolled ventricular rate are at major risk for complications and are not candidates for elective dental care. The presence of pathologic Q waves is a clinical predictor of intermediate risk for perioperative complications. Left ventricular hypertrophy, left bundle branch block, and ST-T wave abnormalities are associated with minor perioperative risk. 8. The use of what drugs in local anesthetics can pose problems for patients with arrhythmias? a. Digoxin b. Vasoconstrictors c. Beta-blockers d. NSAIDs ANS: B The use of vasoconstrictors in local anesthetics poses potential problems for patients with arrhythmias because of the possibility of precipitating cardiac tachycardia or another arrhythmia. A local anesthetic without vasoconstrictor may be used as needed. They should also be avoided in patients taking digoxin because of the potential for inducing arrhythmias. 9. If a vasoconstrictor in local anesthetic is deemed necessary, patients in the low to intermediate risk category and those taking nonselective beta-blockers can safely be given up to ____ cartridge(s) containing 1:100,000 epinephrine. a. one b. three c. two d. zero—epinephrine is an absolute contraindication ANS: C These patients can safely be given up to 0.036 mg epinephrine, which is the amount in two cartridges containing 1:100,000 epinephrine. Greater quantities of vasoconstrictor may well be tolerated, but increasing quantities are associated with increased risk for adverse cardiovascular effects. 10. Due to the rapid absorption of a high concentration of epinephrine and the potential for adverse cardiovascular effects, the use of gingival retraction cord impregnated with epinephrine should be avoided for patients at cardiac risk. What might be used as an alternative? a. Tetrahydrozoline b. Oxymetazoline c. Either A or B d. Neither A nor B ANS: C For patients at all levels of cardiac risk, the use of gingival retraction cord impregnated with epinephrine should be avoided because of the associated rapid absorption of a high concentration of epinephrine and the potential for adverse cardiovascular effects. As an alternative, plain cord saturated with tetrahydrozoline HCl 0.05% or with oxymetazoline HCl 0.05% provides gingival effects equivalent to those of epinephrine without the adverse cardiovascular effects.

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    1 Chapter 06: Heart Failure (or Congestive Heart Failure) Little: Dental Management of the Medically Compromised Patient, 9th Edition MULTIPLE CHOICE 1. Which of the following is the most common underlying cause of heart failure in the United States? a. Dilated cardiomyopathy b. Coronary heart disease c. Valvular heart disease d. Hypertension ANS: B The most common underlying cause of heart failure in the United States is coronary heart disease (secondary to atherosclerosis), accounting for 60% to 75% of cases, with cardiomyopathy, hypertension, and valvular heart disease also well-recognized contributory conditions. The second most common cause of heart failure, accounting for about one fourth of all cases, is dilated cardiomyopathy. 2. Most of the acquired disorders that lead to heart failure result in initial failure of the ________. a. bundle of His b. mitral valve c. right ventricle d. left ventricle ANS: D Left ventricular heart failure (LVHF) often is followed by failure of the right ventricle. In adults, left ventricular involvement is almost always present, even if the clinical manifestations are primarily those of right ventricular dysfunction (fluid retention without dyspnea or rales). 3. The outstanding symptom of left ventricular heart failure is ________. a. dyspnea b. dysphagia c. cyanosis d. rales ANS: A The outstanding symptom is dyspnea, which results from the accumulation or congestion of blood in the pulmonary vessels—hence the designation congestive heart failure. Acute pulmonary edema is often the result of left ventricular failure. Left-sided heart failure leads to pulmonary hypertension, which increases the work of the right ventricle, pumping against increased pressure, often culminating in right-sided heart failure. 4. What is one reason the prognosis for patients with heart failure is poor? a. The symptoms reflect respective ventricular dysfunction. b. Because loss of life due to it cannot be modified by early identification and treatment. c. Primarily because auscultation often reveals a laterally displaced apical impulse caused by left ventricular hypertrophy. d. It is a progressive disease with symptoms that worsen over time. ANS: D Heart failure also predisposes the patient to ischemic stroke, the risk for which is twice as high as normal . The prognosis is better if the underlying cause can be treated. One year after the diagnosis of heart failure, 20% of patients will succumb to the disease. In people diagnosed with it, sudden death occurs six to nine times the rate for the general population. 5. Which of these symptoms and signs of heart failure worsens when the patient assumes a recumbent or semi-recumbent position? a. Orthopnea b. Paroxysmal nocturnal dyspnea (PND) c. Cheyne–Stokes respiration d. Tachycardia ANS: A Most patients with mild to moderate heart failure do not exhibit orthopnea when treated adequately. Paroxysmal nocturnal dyspnea (PND) is an attack of sudden, severe shortness of breath awakening the patient from sleep. PND is a common clinical feature associated with Cheyne–Stokes respiration in heart failure patients. With Cheyne–Stokes respiration, central regulation of respiration may be impaired, resulting in alternating cycles of hyperventilation with periods of central apnea. Tachycardia (increased pulse rate) indicates increased myocardial oxygen demand, coronary blood flow, and overall myocardial performance. 6. What is a primary reason outcomes in the care of patients with heart failure are not significantly improving? a. Management of heart failure is complex and generally applied in a graduated approach. b. An algorithm for drug treatment of heart failure has not been found. c. Patient compliance with treatment recommendations is notoriously poor. d. Drugs that modulate or decrease neurohormonal activity have not yet become the foundation of treatment. ANS: C As with many conditions, a large degree of success of medical therapy depends upon patient compliance with treatment recommendations. Since many of these patients are treated with a plethora of drugs, it is important to monitor and/or encourage their compliance. However, a relatively recent study has demonstrated that even after telemonitoring and multiple verbal reminders, the overall impact on improving outcomes in heart failure was not significant.

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    2 7. Which of the following categories of drugs is considered to be first-line therapy for the treatment of heart failure? a. Digitalis glycosides b. β -Adrenergic blockers c. Angiotensin-converting enzyme (ACE) inhibitors d. Angiotensin receptor blockers (ARBs) ANS: C ACE inhibition with enalapril has been shown to reduce mortality from heart failure by 20% to 40%. The ACE inhibitors are typically prescribed along with or following diuretic therapy and they decrease the need for large doses of diuretics as well as some of the adverse metabolic effects of the diuretics. 8. If drug therapy is found to be inadequate in controlling patients with severe, refractory heart failure ________. a. mechanical and/or surgical intervention may be introduced b. end-of-life care with hospice is the only remaining option c. medical therapy will depend solely upon patient compliance with experimental recommendations d. diuretic therapy becomes a patient’s “long shot” final attempt at improved health ANS: A Mechanical and surgical intervention may be provided. These measures may include intra-aortic balloon counterpulsation, left ventricular assist device (LVAD), and heart transplantation. Other therapies include implantable cardioverter-defibrillator (ICD), 9. Dental patients with a previous history of heart failure or who are asymptomatic have ________ heart failure. a. decompensated b. compensated c. provisional d. orthopnea ANS: B With decreasing cardiac output, stimulation of the renin–angiotensin system and the sympathetic nervous system (neurohumoral responses) occur in an attempt to compensate for the loss of function. The effects of these responses include increased heart rate and myocardial contractility, increased peripheral resistance, sodium and water retention, redistribution of blood flow to the heart and brain, and an increased efficiency of oxygen utilization by the tissues. If these responses result in improved cardiac output with an elimination of symptoms, the condition is termed compensated heart failure. Symptomatic heart failure is termed decompensated . 10. To what key information source must a dentist refer in determining the risk involved in treating a heart failure patient? a. The New York Heart Association’s classification system of heart failure b. Clinical manifestations of digitalis toxicity c. All details the patient included in the dental history d. The patient’s physician ANS: D In most cases, it will be necessary for the dentist to obtain a medical consultation with the patient’s cardiologist in order to determine physical status, laboratory test results, level of control, compliance with medications and recommendations, and overall stability. The American College of Cardiology and the American Heart Association have published guidelines which can help to make this determination. These guidelines can be applied to the provision of dental care and be of significant value to the dentist in making a determination of risk.

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    1 Chapter 07: Pulmonary Disease Little: Dental Management of the Medically Compromised Patient, 9th Edition MULTIPLE CHOICE 1. The most important cause of chronic obstructive pulmonary disease (COPD) in the world is ________. a. occupational pollutants b. environment pollutants c. tobacco smoking d. allergy ANS: C Worldwide, tobacco smoking is the most important cause of COPD. Approximately 12.5% of current smokers, 9% of former smokers, and 8% of those exposed to passive smoke have COPD. Smoking also accounts for 85% to 90% of COPD-related deaths in both men and women. The risk for development of COPD is dose related and increases with the number of cigarettes smoked per day and duration of smoking. 2. Which of the following is true of the signs and symptoms associated with COPD for patients who were historically referred to as “blue bloaters” or “pink puffers”? a. Patients who had emphysema were traditionally known as “pink puffers” because they demonstrated enlarged chest walls, giving them a “barrel-chested” appearance. b. Currently, it is recognized that most patients with COPD may exhibit features of both diseases. c. “Blue bloaters” demonstrated weight loss with progression of the disease and a lack of cyanosis. d. A and B e. B and C ANS: D “Blue bloaters” were presented as patients who had chronic bronchitis. They were described as sedentary, overweight, cyanotic, edematous, and breathless. Patients diagnosed with emphysema, “pink puffers,” exhibit weight loss with disease progression, severe exertional dyspnea with a mild, nonproductive cough, lack of cyanosis, and pursing of the lips with effort to forcibly exhale air from the lungs. Most patients with COPD may exhibit features of both diseases. 3. Which two of the following are true of the arterial blood gas measurement for a patient with emphysema? 1. Elevated partial pressure of carbon dioxide 2. Normal partial pressure of carbon dioxide 3. Decreased partial pressure of carbon dioxide 4. Decreased partial pressure of oxygen 5. Normal partial pressure of oxygen a. 1, 4 b. 2, 4 c. 3, 4 d. 1, 5 e. 2, 5 ANS: B Patients with emphysema have a relatively normal partial pressure of carbon dioxide and a decreased partial pressure of oxygen. Patients with chronic bronchitis have an elevated partial pressure of carbon dioxide and a decreased partial pressure of oxygen. 4. Which of the following is true of dental management for a patient with COPD? a. The appointment should be rescheduled if pulse oximetry finds the oxygen saturation level to be less than 91%. b. The patient should be placed in a supine position for treatment in the dental chair. c. Prilocaine is the only local anesthetic that is recommended for use with this category of patient. d. Nitrous oxide is preferred over diazepam (Valium) for a patient with severe COPD. ANS: A A patient coming to the office for routine dental care who displays shortness of breath at rest, a productive cough, upper respiratory infection, or an oxygen saturation level less than 91% (as determined by pulse oximetry) is unstable, and the appointment should be rescheduled and an appropriate referral for medical attention should be made. Patients should be placed in a semisupine or upright chair position for treatment, rather than in the supine position, to prevent orthopnea and a feeling of respiratory discomfort. No contraindication to the use of local anesthetic has been identified. If sedative medication is required, low-dose oral diazepam may be used. Nitrous oxide–oxygen inhalation sedation should not be used in patients with severe COPD and emphysema because gas may accumulate in air spaces of the diseased lung.

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    2 5. Which of the following chronic inflammatory diseases of the airways is characterized by reversible episodes of increased airway hyperresponsiveness? a. Emphysema b. Asthma c. Chronic bronchitis d. A and B e. B and C ANS: B Asthma is a chronic inflammatory disease of the airways characterized by reversible episodes of increased airway hyperresponsiveness resulting in dyspnea, coughing, and wheezing. Chronic bronchitis and emphysema are forms of chronic obstructive pulmonary disease (COPD), which is a general term for pulmonary disorders characterized by chronic airflow limitation from the lungs that is not fully reversible. 6. Which of the following medications is associated with “triad asthmaticus”? a. Methotrexate b. Nonspecific beta-blockers c. Aspirin d. Penicillin ANS: C Aspirin causes bronchoconstriction in about 10% of patients with asthma, and sensitivity to aspirin occurs in 30% to 40% of people with asthma who have pansinusitis and nasal polyps (the so-called triad asthmaticus). The ability of aspirin to block the cyclooxygenase pathway appears causative. 7. Which of the following agents is currently regarded as the first-line medication for long-term control of asthma? a. β -Adrenergic agonist b. Corticosteroid c. Theophylline d. Cromolyn sodium ANS: B Current guidelines recommend a “stepwise” approach with the use of inhaled antiinflammatory agents as first-line drugs (the preferred inhalational agent is a corticosteroid preparation, with a leukotriene inhibitor as an alternative) for the lo ng-term management and prophylaxis of persistent asthma. β -Adrenergic agonists are recommended for intermittent asthma and are secondary agents that should be added (i.e., not to be used alone) for persistent asthma when antiinflammatory drugs are inadequate alone. 8. Which of the following is the drug of choice for relief of an acute asthma attack? a. Oral anticholinergic b. Inhalation corticosteroid c. Short-acting β 2 -adrenergic agonist d. Inhaled cromolyn sodium ANS: C For relief of an acute asthma attack, inhaled short-acting β 2 -adrenergic agonists are the drugs of choice because of their fast and notable bronchodilatory and smooth muscle relaxation properties. Short-acting β 2 -adrenergic agonists produce bronchodilation by activating β 2 receptors on airway smooth muscle cells, generally in 5 minutes or less. Inhalation corticosteroids, inhaled cromolyn sodium, and oral anticholinergics are not used for this purpose because of slow onset of action. 9. The use of local anesthetic without epinephrine or levonordefrin may be advisable for patients with moderate to severe asthma because _________ preservatives are found in local anesthetic solutions that contain epinephrine or levonordefrin. a. alum b. sulfite c. methylparaben d. sodium chloride ANS: B In 1987, the U.S. Food and Drug Administration (FDA) warned that drugs containing sulfites were a cause of allergic-type reaction in susceptible individuals. Sulfite preservatives are found in local anesthetic solutions that contain epinephrine or levonordefrin, although the amount of sulfite in a local anesthetic cartridge is less than the amount commonly found in an average serving of certain foods. 10. According to the World Health Organization (WHO), approximately what percentage of the world’s population is infected with tuberculosis? a. One tenth b. One eighth c. One quarter d. One third ANS: D The World Health Organization (WHO) estimates that one third of the world’s population—representing 2 billion people—is infected. This disease kills more adults worldwide each year than does any other single pathogen.

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    3 11. Which of the following is true regarding laboratory tests for tuberculosis? a. A positive tuberculin (Mantoux) skin test (TST) means that the person has clinically active tuberculosis. b. The interferon-gamma release assay (IGRA) is administered by intradermal injection of 0.1 mL of purified protein derivative (PPD). c. All dentists should undergo annual tuberculin skin testing. d. The IGRA test can discriminate active from latent infection. ANS: C All persons who are at risk for development of TB—including dentists—should undergo tuberculin skin testing annually. Without treatment, approximately 5% of skin test converters develop TB within 2 years; another 5% develop it later. A positive result on a tuberculin (Mantoux) skin test (TST) presumptively means that the person has been infected. It does not mean that the person has clinically active TB. IGRAs (interferon-gamma release assays) are performed on fresh whole blood. Neither the TST nor the IGRA can discriminate active from latent infection. 12. For which of the following categories of patients is treatment in the dental office contraindicated? 1. Patients with a positive tuberculin test 2. Patients with a history of tuberculosis 3. Patients with clinically active sputum-positive tuberculosis a. 1, 2, 3 b. 1, 2 c. 2, 3 d. 3 ANS: D Patients with recently diagnosed, clinically active TB and positive sputum cultures should not be treated on an outpatient basis. Treatment is best rendered in a hospital setting with appropriate isolation, sterilization (mask, gloves, gown), and special engineering control (ventilation) systems and filtration masks. The patient with a history of tuberculosis who is found to be free of active disease and is not immunosuppressed may be treated with the use of standard precautions. Patients with a positive tuberculin skin test may be treated in a normal manner with the use of standard precautions. 13. Any time a patient demonstrates unexplained, persistent signs or symptoms that may be suggestive of TB, or has a positive result on skin testing or IGRA, and has not been given follow-up medical care, _________. a. it is appropriate to treat the patient using standard precautions b. respiratory equipment should be used during provision of dental care c. only treatment that utilizes a rubber dam should be provided d. dental care should not be rendered, and the patient should be referred to a physician for evaluation ANS: D Dental care should not be rendered. If a health care provider is exposed to TB, the provider should be evaluated for skin test conversion. Converters should be treated promptly with isoniazid.

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