AGD Fellowship Review Course: Oral Pathology, Oral Medicine, and Medical Emergencies

Comprehensive practice flashcards covering medical evaluation, systemic diseases, emergencies, and oral pathology for the AGD Fellowship Review Course.

How does the American Society of Anesthesiologists (ASA) classify an ASA III patient?

A patient with moderate to severe systemic disease resulting in substantive functional limitations to daily activity, with probable impact on anesthesia and surgery (e.g., poorly controlled diabetes or hypertension, COPD, morbid obesity with $\text{BMI} \ge 40$, active hepatitis, or history of MI/CVA/TIA $>3\,\text{months}$$ ago).

What blood pressure reading constitutes a hypertensive emergency in the dental setting, and what is the recommended protocol?

A blood pressure $\ge 180/110\,\text{mmHg}$ (or any elevated pressure accompanied by symptoms such as headache, nausea, epistaxis, or anxiety); elective dental care must be deferred and the patient referred for immediate medical evaluation.

According to the lecture, what are the BMI thresholds for Class I through Class IV obesity?

Class I: $\text{BMI } 30\text{--}34.9$; Class II: $\text{BMI } 35\text{--}39.9$ (severely obese); Class III: $\text{BMI } 40\text{--}49.9$ (morbidly obese); Class IV: $\text{BMI} \ge 50$ (super obese).

Which high-risk cardiac conditions require antibiotic prophylaxis prior to dental procedures to prevent infective endocarditis?

Prosthetic cardiac valves or prosthetic material used for valve repair; history of previous, relapse, or recurrent IE; unrepaired cyanotic congenital heart disease (CHD); repaired CHD within $6\,\text{months}$ post-repair; repaired CHD with residual defects; surgical or transcatheter pulmonary artery valve or conduit placement; and cardiac transplants if valvulopathy develops.

Which dental procedures require antibiotic prophylaxis in susceptible infective endocarditis patients, and which do not?

Required: All dental procedures involving manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of oral mucosa. Not required: Routine anesthetic injections through noninfected tissue, taking dental radiographs, placing or adjusting removable prosthodontic/orthodontic appliances, and natural shedding of deciduous teeth.

What is the standard oral antibiotic prophylactic regimen for infective endocarditis according to the AHA guidelines, and which antibiotic is explicitly no longer recommended?

Amoxicillin $2\,\text{g}$ orally for adults ($50\,\text{mg/kg}$ for children) single dose $30\text{--}60\,\text{min}$ before the procedure; clindamycin is no longer recommended.

What oral antibiotic regimens should be administered to an adult patient requiring infective endocarditis prophylaxis who has a penicillin or ampicillin allergy?

Cephalexin $2\,\text{g}$, or Azithromycin or Clarithromycin $500\,\text{mg}$, or Doxycycline $100\,\text{mg}$ as a single dose $30\text{--}60\,\text{min}$ prior to the procedure (cephalosporins should be avoided if there is a history of anaphylaxis, angioedema, or urticaria to penicillins).

What are the primary oral adverse effects associated with calcium channel blockers and ACE inhibitors?

Calcium channel blockers can cause gingival overgrowth and xerostomia; ACE inhibitors can provoke angioedema.

What is the maximum recommended dose of epinephrine in local anesthetic for a patient with symptomatic or high-risk cardiovascular disease such as angina?

$0.04\,\text{mg}$ of epinephrine (equivalent to approximately two cartridges of $1:100{,}000$ epinephrine).

What are the immediate emergency management steps for a patient experiencing a myocardial infarction in the dental office?

Terminate procedure and activate EMS; position comfortably (often upright); monitor vitals continuously every $5\,\text{minutes}$; administer Nitroglycerin if systolic $\text{BP} > 90\,\text{mmHg}$; administer oxygen only if $\text{SpO}_2 < 94\%$ or respiratory distress; administer a $325\,\text{mg}$ chewable or powdered dose of aspirin immediately; manage pain and prepare for cardiac arrest.

How long must elective dental care be delayed following an acute myocardial infarction?

No elective dental care within $30\,\text{days}$ (the historical $6\text{-month}$ delay is no longer applicable), with most recommending a cautious $4\text{--}6\text{-week}$ stabilization period.

How do aspirin and clopidogrel (Plavix) differ in their mechanisms of antiplatelet action?

Aspirin is a cyclooxygenase (COX-1) inhibitor that irreversibly inhibits platelet function for their entire lifespan ($\sim 10\,\text{days}$); clopidogrel selectively inhibits the binding of ADP to its platelet P2Y12 receptor.

Which clotting factors are dependent on Vitamin K, and what is the target therapeutic INR range for patients on warfarin therapy?

Factors II, VII, IX, and X; the target therapeutic INR is usually $2.0\text{--}3.0$.

What INR threshold allows minor dental surgery to be performed safely without altering or discontinuing warfarin anticoagulation?

An INR between $2.0$ and $3.5$, verified within $24\text{--}72\,\text{hours}$ prior to the surgical procedure.

Which coagulation pathways and factors are evaluated by the Prothrombin Time (PT) versus the activated Partial Thromboplastin Time (aPTT)?

PT evaluates the extrinsic and common pathways (Factors VII, X, V, II, fibrinogen; activated by tissue thromboplastin; normal $11\text{--}15\,\text{s}$); aPTT evaluates the intrinsic and common pathways (Factors XII, PK, HK, XI, IX, VIII, X, V, II, fibrinogen; normal $25\text{--}35\,\text{s}$).

What are the specific factor deficiencies in Hemophilia A, Hemophilia B, and Hemophilia C?

Hemophilia A is Factor VIII deficiency; Hemophilia B (Christmas Disease) is Factor IX deficiency; Hemophilia C is Factor XI deficiency.

What is the normal circulating platelet count, and at what level can clinical surgical bleeding complications occur?

Normal platelet count is $140{,}000\text{--}400{,}000/\mu\text{L}$; clinical bleeding problems can occur if the platelet count drops below $50{,}000/\mu\text{L}$.

What are the mechanisms of action of the topical hemostatic agents Surgicel and Tranexamic acid?

Surgicel (oxidized regenerated cellulose) swells on contact with blood to increase local pressure and facilitate clotting; Tranexamic acid acts as a competitive inhibitor of plasminogen activation to prevent fibrinolysis.

How do Chronic Bronchitis ("Blue Bloater") and Emphysema ("Pink Puffer") clinically differ in COPD?

Chronic Bronchitis presents with onset around $50\,\text{years}$, frequent overweight status, chronic productive cough with copious mucopurulent sputum, and mild dyspnea; Emphysema presents around $60\,\text{years}$, thin barrel-chested appearance, non-prominent cough with scanty sputum, and severe dyspnea.

Which antibiotics must be avoided in dental patients taking theophylline for respiratory disease due to toxicity risks?

Erythromycin, ciprofloxacin, and other macrolide antibiotics (they inhibit theophylline metabolism leading to theophylline toxicity).

What are the emergency drug dosages for managing an acute, severe asthma attack that is unresponsive to a beta-2 agonist inhaler?

Subcutaneous or intramuscular injection of epinephrine $0.3\,\text{mL}$ of a $1:1000$ dilution.

How long should elective dental care be deferred following a stroke (cerebrovascular accident)?

Elective dental treatment can resume after $>90\,\text{days}$ following a stroke.

What defines generalized convulsive status epilepticus, and what is the emergency medical management if seizure activity lasts $>5\,\text{minutes}$?

A continuous seizure or repetitive recurrence of seizures without recovery between attacks; activate EMS, manage CAB/BLS, and administer IV anticonvulsants (Lorazepam $0.1\,\text{mg/kg}$ up to $4\,\text{mg/dose}$, or Midazolam $0.2\,\text{mg/kg}$ up to $10\,\text{mg}$).

What are the immunologic mechanisms for the four types of Gell and Coombs hypersensitivity reactions?

Type I: Immediate, humoral, IgE-mediated (anaphylaxis, atopy); Type II: Cytotoxic, humoral, IgG/IgM-mediated (transfusion reactions); Type III: Humoral, immune complex-mediated (serum sickness, vasculitis); Type IV: Delayed, cell-mediated by sensitized T cells (contact dermatitis).

What laboratory thresholds in HIV-infected patients indicate severe immunosuppression requiring antibiotic prophylaxis, platelet transfusion, or contraindication to surgery?

Antibiotic prophylaxis is required if severe neutropenia ($\text{ANC} < 500\,\text{cells/mm}^3$); platelet transfusion should be considered if platelet count is $< 50{,}000/\mu\text{L}$; surgical procedures are contraindicated in severe anemia ($\text{hemoglobin} < 11\,\text{g/dL}$).

What are the diagnostic blood test criteria for diabetes mellitus based on fasting plasma glucose, oral glucose tolerance test, and HbA1c?

Fasting Plasma Glucose (FPG) $\ge 126\,\text{mg/dL}$; Oral Glucose Tolerance Test (OGTT) $\ge 200\,\text{mg/dL}$; and $\text{HbA1c} \ge 6.5\%$.

What dietary and medication precautions should be taken for a diabetic patient on insulin scheduled for a morning dental appointment while NPO?

Hold the morning dose of rapid-acting insulin and hold sulfonylureas that day to prevent severe hypoglycemia.

How does thyroid dysfunction affect serum calcium homeostasis?

Hypothyroidism promotes hypercalcemia, whereas hyperthyroidism promotes hypocalcemia.

What is the optimal timing for dental treatment in patients undergoing regularly scheduled hemodialysis for end-stage renal disease?

Dental treatment should be performed on the day AFTER hemodialysis to allow heparin clearance and stabilization of fluid/electrolyte balance.

What are the clinical differences between Ulcerative Colitis and Crohn's disease regarding gastrointestinal and oral manifestations?

Ulcerative Colitis is a mucosal disease limited to the large intestine and rectum, associated with aphthous-like ulcers and pyostomatitis vegetans; Crohn's disease affects the entire bowel wall thickness anywhere along the alimentary tract with 'skip lesions', presenting orally with cobblestone ulcerations and orofacial granulomatosis.

What specific genetic mutation causes Sickle Cell Anemia?

A point mutation resulting in the substitution of the amino acid valine for glutamic acid in the beta-globin chain.

What is the American Dental Association's consensus recommendation regarding routine antibiotic prophylaxis for patients with total joint replacements?

Routine prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection; practitioners should follow the specific recommendation of the patient's orthopedic surgeon/physician.

Under the FDA pregnancy classifications, which category does lidocaine fall into compared to articaine, bupivacaine, and mepivacaine?

Lidocaine is a Class B drug, whereas Articaine, Bupivacaine, and Mepivacaine are Class C drugs.

What radiation dose threshold increases the risk of osteoradionecrosis (ORN), and what hyperbaric oxygen (HBO) protocol is recommended for extractions?

Total radiation dose exceeding $6000\,\text{cGy}$ ($60\,\text{Gy}$); the Marx HBO protocol utilizes $20$ pre-operative dives and $10$ post-operative dives.

What are the three essential diagnostic criteria for Medication-Related Osteonecrosis of the Jaw (MRONJ)?

1. Current or previous treatment with antiresorptive or antiangiogenic agents; 2. Exposed necrotic bone or bone that can be probed through a fistula in the maxillofacial region persisting for $>8\,\text{weeks}$; 3. No history of radiation therapy to the jaws or obvious metastatic disease to the jaws.

Why is breathing into a paper bag no longer recommended for managing hyperventilation syndrome?

Hyperventilation causes excessive loss of $\text{CO}_2$ resulting in respiratory alkalosis; paper bag rebreathing is dangerous because it can cause severe hypoxia if the underlying etiology is metabolic acidosis, pulmonary embolism, or myocardial infarction.

What are the characteristic features of the 'three Ps' of reactive gingival nodules?

Pyogenic granuloma (red, vascular, bleeds easily, associated with pregnancy/calculus); Peripheral ossifying fibroma (cellular fibrous stroma with mineralized bone/cementum-like calcifications); Peripheral giant cell granuloma (vascular with multinucleated giant cells, dark red/purple, cupping resorption of bone).

What benign mucosal condition is shown, which characteristically diminishes or disappears when the cheek is stretched?

Leukoedema

What systemic autoimmune disease presents with the characteristic facial butterfly (malar) rash shown here?

Systemic Lupus Erythematosus (SLE)

How do Pemphigus vulgaris and Mucous membrane pemphigoid differ in their histopathology and target antigens?

Pemphigus vulgaris involves autoantibodies against desmosomes (desmogleins) producing intraepithelial split and acantholysis (positive Nikolsky sign); Mucous membrane pemphigoid involves autoantibodies targeting hemidesmosomes in the basement membrane producing a subepithelial separation.

What reactive oral mucosal condition of the hard palate is pictured, commonly associated with ill-fitting dentures and Candida albicans?

Inflammatory papillary hyperplasia

What benign epithelial lesion with a verrucous/papillary surface is shown here, typically associated with HPV types 6 and 11?

Squamous papilloma

What pediatric condition, also known as multifocal epithelial hyperplasia, presents with the multiple labial papules shown and is caused by HPV 13 and 32?

Heck's disease

What are the most common high-risk intraoral sites for oral squamous cell carcinoma?

Lateral and ventral borders of the tongue ($>50\%$) and the floor of the mouth (${\sim}35\%$).

What chronic bone disorder presents with the classic 'cotton wool' radiopaque skull appearance shown here and elevated serum alkaline phosphatase?

Paget's disease (Osteitis deformans)

What key clinical feature distinguishes cemento-osseous dysplasias from apical inflammatory lesions?

Associated teeth in cemento-osseous dysplasia maintain pulpal vitality, and the condition requires no endodontic treatment.

What is the classic radiographic appearance of an ossifying fibroma in the mandible?

A well-demarcated, expansile unilocular mixed radiolucent-radiopaque lesion that characteristically causes downward bowing of the inferior border of the mandible.

What specific type of odontogenic hamartoma is depicted in this occlusal radiograph, characterized by multiple small, rudimentary tooth-like structures (denticles)?

Compound odontoma

What are the defining radiographic features of a cementoblastoma?

A well-demarcated dense radiopacity with a uniform radiolucent peripheral rim that is fused directly to and obliterates the apex of a tooth root, most commonly the permanent mandibular first molar.

What malignancy of plasma cells is characterized by the multiple distinct, 'punched-out' skull radiolucencies shown in this radiograph?

Multiple myeloma

What hereditary dental condition presents with the opalescent, amber-to-brown discolored teeth and marked attrition shown here?

Dentinogenesis imperfecta

What triad of clinical and radiographic features characterizes Gardner Syndrome?

Multiple osteomas, multiple supernumerary teeth/odontomas, and premalignant adenomatous intestinal polyps (with high risk of early colorectal adenocarcinoma), alongside epidermoid cysts and desmoid tumors.

What hereditary condition displays severe hypodontia with conical-shaped crowns on radiography, associated clinically with heat intolerance and sparse hair?

Ectodermal dysplasia