SBAs and EMQs for Human Disease (Medicine) in Dentistry
SBAs and EMQs for Human Disease (Medicine) in Dentistry
Oluyori K. Adegun BDS MSc CILT MFDS RCS(Ed)
PhD PGCAP FHEA
Honorary Clinical Senior Lecturer in Clinical Human Health and Disease, Institute of Dentistry, Bart’s and London School of Medicine and Dentistry, Queen Mary, University of London
Speciality Registrar in Oral and Maxillofacial Pathology, University College London Hospitals NHS Foundation Trust
Clinical Senior Lecturer/Honorary Consultant in Oral Medicine and Lead for Quality Assurance at Bart’s and The London School of Medicine and Dentistry, Queen Mary University of London/Bart’s Health NHS Trust
Farida Fortune MB BS FDS RCS Eng. FRCP PhD CBE
Professor of Medicine in Relation to Oral Health/Honorary Consultant in Oral Medicine, Clinical and Diagnostic Oral Sciences, Bart’s and The London School of Medicine and Dentistry, Queen Mary, University of London
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PREFACE
Throughout the world, advances in medicine combined with an ageing population and an increasing emphasis on healthcare delivery as an outpatient and in primary care has resulted in an increasing number of patients with complex medical conditions—who are also taking multiple medications— seeking dental treatment from dental care practitioners in general practice. Whereas previously these patients would have been treated on an inpatient basis, there is an increasing emphasis on outpatient treatment.
These changing trends underline the importance that dental healthcare providers in both general and specialty practice have a sound and up-to-date knowledge of human disease (medicine) in dentistry and clinical pharmacology and therapeutics.
During the years of teaching human disease (medicine) in dentistry to undergraduate dental students, we have regularly been asked to recommend reading and self-assessment resources for self-directed learning to facilitate preparation for examinations. For the former a repertoire of textbooks, case reports, and serial journal articles specifically written for medicine in dentistry exists. However, for the latter there remains no specifically prepared self-assessment material to refer students to. This impacts on their ability to engage in formative learning, reflect, and identify their learning needs, as well as prepare for their all-important summative examinations. To address this gap, we have written a dedicated self-assessment material, which:
Is presented using current assessment formats (i.e. SBAs and EMQs), which are currently considered to be the formats of choice for integrated knowledge tests on the human disease (medicine) in dentistry
Covers specific learning outcomes for the human disease course as outlined in the General Dental Council’s (GDC) Preparing for Practice document
Incorporates clinical scenarios designed to test the recognition of oral and systemic signs and symptoms, and selection of the most appropriate investigations and management, all of which should foster the development of clinical problem-solving skills
Facilitates formative learning by ensuring each question is accompanied by the answer and the rationale using clear facts explaining why the correct response is right and why the other responses are less plausible. This approach will help evaluate individual learning needs thereby identifying areas which may require further reading
Is written by specialists experienced in the design and delivery of the human disease (medicine) in dentistry curriculum and are familiar with the common presentations, pathologies, and dilemmas encountered while working within the specialty
We hope that you will find this formative assessment resource to be stimulating and interesting and that it will help you to develop the necessary knowledge base, problem-solving, and clinical skills
required to deliver high-quality and safe patient care in your everyday practice as a dental healthcare practitioner. It also anticipated that exposure to a variety of clinical signs and symptoms from the different systems in the body while using this book will contribute towards the knowledge of the most appropriate clinical specialty to refer a patient to for further care.
Oluyori K. Adegun, John A.G. Buchanan, and Farida Fortune
ACKNOWLEDGEMENTS
We would like to thank the editorial staff of Oxford University Press who encouraged us to produce this self-test learning resource in which we have endeavoured to incorporate clinical scenarios designed to test reasoning skills and develop the cognitive processes required to navigate the complexities of medicine in relation to dentistry. We are particularly grateful to Geraldine Jeffers and her team for their close support in getting this project underway. Our sincere thanks to Dennis Ola, Otto Mohr, and Alina Roser who provided constructive feedback on draft questions. Finally, profound thanks go to our families for their moral support and endless patience while we were writing this book.
ABBREVIATIONS
ABPA Allergic bronchopulmonary aspergillosis
ACE Angiotensin-converting enzyme
ACTH Adrenocorticotropic hormone
AD Addison’s disease
AED Automated external defibrillator
AF Atrial fibrillation
ALL Acute lymphoblastic leukaemia
AML Acute myeloblastic leukaemia
ANCA Antineutrophil cytoplasmic antibodies
APTT Activated partial thromboplastin time
ASA American Society of Anesthesiologists
BAD Bipolar affective disorder
BCR Breakpoint cluster region
BMD Bone mineral density
BMS Burning mouth syndrome
BPH Benign prostatic hyperplasia
BT Bleeding time
CDT Carbohydrate-deficient transferrin
CHHD Clinical Human Health and Disease
CN Cranial nerves
CNS Central nervous system
COPD Chronic obstructive pulmonar y disease
CRP C-reactive protein
CT Computed tomography
DEXA Dual-energy X-ray absorptiometry
DM Diabetes mellitus
DMARD Disease-modifying antirheumatic drug
DS Down’s syndrome
EMQs Extended Matching Questions
ESR Erythrocyte sedimentation rate
FBC Full blood count
FNAC Fine needle aspiration cytology
GABA Gamma-aminobutyric acid
GCA Giant cell arteritis
GDC General Dental Council
GDP General dental practitioner
GFR Glomerular filtration rate
GGT Gamma-glutamyl transpeptidase
GH Growth hormone
GHRH Growth hormone releasing hormone
GP General practitioner
GVHD Graft-versus-host disease
HDL High density lipoprotein
HHD Human Health and Disease
HHT Hereditary haemorrhagic telangiectasia
HZ Herpes zoster
IBD Inflammatory bowel disease
IBS Irritable bowel syndrome
ICU Intensive care unit
INR International normalized ratio
LCH Langerhans cell histiocytosis
LDL Low-density lipoprotein
MC Microscopic colitis
MCV Mean cell volume
MM Multiple myeloma
MPNST Malignant peripheral nerve sheath tumour
MRONJ Medication-related osteonecrosis of the jaw
MRSA Methicillin-resistant Staphylococcus aureus
MSH Melanocyte-stimulating hormone
NBCCS Naevoid basal cell carcinoma syndrome
NICE National Institute for Clinical Excellence
NK Natural killer
NSAID Non-steroidal anti-inflammatory drugs
NSCLC Non-small cell lung cancer
OCD Obsessive-compulsive disorder
PCD Primary ciliary dyskinesia
PEA Pulseless electrical activity
PK Pyruvate kinase
PTH Parathyroid hormone
RAS Renin-angiotensin system
RBC Red blood cell
RPR Rapid plasma reagin
SBA Single best answer
TSC Tuberous sclerosis complex
TSH Thyroid-stimulating hormone
UK United Kingdom
UKMI UK Medicines Information
UMN Upper motor neurone
VDRL Venereal Disease Research Laboratory
VF Ventricular fibrillation
VN Virchow node
VT Ventricular tachycardia
VZV Varicella zoster virus
SINGLE BEST ANSWER (SBA) QUESTIONS
Introduction 2
Therapeutics in dentistry 3
Orofacial manifestations of systemic diseases 7
Haematological diseases 11
Special investigations in relation to medicine in dentistry 15
Medical emergencies in dentistry 18
Rheumatological diseases 21
Cardiac diseases 23
Neurological diseases 25
Endocrine diseases 27
Infectious diseases 29
Psychiatry in dentistry 30
Immunological diseases 32
Hand manifestations of systemic diseases 33
Gastrointestinal diseases 34
Renal diseases 35
Respiratory diseases 36
Preoperative anaesthetic care 38
Introduction
Well-written single best answer (SBA) questions are currently held to be the format of choice for knowledge assessments in high stakes undergraduate and postgraduate examinations. They may also be useful adjunct to learning. In this chapter, each SBA consists of a clinical scenario, associated question, and a list of five plausible options. Of the five options, the MOST likely option is the correct answer, while the other four are incorrect options. In some of the more challenging SBAs one of the four incorrect answers may be partially correct but does not answer the question as well as the correct response.
Therapeutics in dentistry
. A mucous membrane pemphigoid patient on dapsone has developed massive red blood cell haemolysis, a known side effect. Which ONE of the following characteristic clinical features is this patient MOST likely to manifest?
A. Bradycardia
B. Dark urine colour
C. Lymphadenopathy
D. Pale stool
E. Spontaneous gingival bleeding
2. A patient with atrial fibrillation and on warfarin is aware that certain drugs can interact with their medication to promote bleeding. Which ONE of the following drugs can be safely prescribed for dental treatment?
A. Erythromycin
B. Metronidazole
C. Miconazole
D. Nystatin
E. Tetracycline
3. A 55-year-old patient is receiving prednisolone for polymyalgia rheumatica. Which ONE of the following advisories/information is MOST likely to be of benefit to this patient?
A. Advise adrenocortical suppression is unlikely
B. Advise blood test to check triglyceride and potassium levels
C. Advise an initial check of HBAc at 6 months after commencing treatment
D. Advise patient to avoid over the counter NSAID (non-steroidal anti-inflammatory drugs)
E. Advise precautionary treatment for hypertension
4. Post stem cell transplant for multiple myeloma, a patient is being placed on ciclosporin. Which ONE of the following is the MAIN side effect they may develop?
A. Nausea and vomiting
B. Oral thrush
C. Pancytopenia
D. Recurrent oral ulcers
E. Renal failure
5. A patient with well-controlled hyper tension presents with poor oral hygiene and generalized gum enlargement. Which ONE of the following antihypertensive medications is the MOST likely culprit?
A. Amlodipine
B. Atenolol
C. Bendroflumethiazide
D. Losartan
E. Ramipril
6. You are about to prescribe an analgesic for post-extraction pain to a patient on prednisolone. Which ONE of the following analgesics can be SAFELY prescribed to this patient?
A. Aspirin
B. Co-dydramol
C. Diclofenac
D. Mefenamic acid
E. Paracetamol
7. During a consultation you update a patient’s drug history. The patient’s medication includes ramipril, amlodipine, gliclazide, metformin, and simvastatin. Which ONE of the following options BEST describes the different classes of the patient’s medication, respectively?
A. Angiotensin-converting enzyme inhibitor, calcium channel blocker, sulfonylurea, biguanide, and statins
B. Angiotensin II receptor blocker, calcium channel blocker, alpha-glucosidase inhibitors biguanide, and statins
C. Beta blocker, alpha blocker, sulfonylurea, biguanide, and statins
D. Diuretic, calcium channel blocker, glitazone, sulfonyl urea, and statins
E. Vasodilator, beta blocker, sulfonylurea, biguanide, and statins
8. Lichenoid reaction is the histopathological diagnosis for a sore, white lacy-like lesion on the right buccal mucosa of a 60-year-old patient. In view of this finding, you have reviewed the patient’s drug history with a view to identifying the possible causative medication. Which ONE of the following medications is MOST likely to be associated with the patient’s oral finding?
A. Alendronic acid
B. Bendroflumethiazide
C. Co-codamol
D. Pioglitazone
E. Simvastatin
9. A postmenopausal patient can’t immediately recall a medication prescribed by the rheumatologists but remembers the instructions pertaining to it state ‘swallow the medicine with plenty of water before first meal or beverage of the day, remain upright for 30 minutes and wait 30 minutes before eating or using other drugs’. Which ONE of the following medicines is MOST likely been referred to?
A. Bisphosphonates
B. Calcitonin
C. Calcium and vitamin D supplements
D. Hormone replacement therapy
E. Strontium ranelate
0. A patient presents with oral candidiasis (thrush). They are currently taking the following medications: atorvastatin, lansoprazole, ramipril, aspirin, metformin, and amlodipine. Which ONE of the following antifungals is MOST safe to prescribe to manage his thrush?
A. Fluconazole
B. Itraconazole
C. Miconazole
D. Nystatin
E. Terbinafine
. A patient on warfarin suffers from a recurrent infection at the angles of the mouth. They are using a prescribed medication for topical application. The international normalized ratio (INR) which was 2.8 now fluctuates between 3.7 and 4.5. Which one of the following is the MOST likely medication to cause this problem?
A. Betamethasone ointment
B. Chlorhexidine gel
C. Difflam mouthwash
D. Miconazole gel
E. Nystatin suspension
2. A patient with hypertension and high blood cholesterol attends the emergency department with onset of increasingly severe muscular pain. Their medication includes daily simvastatin, aspirin, bendroflumethiazide, and clarithromycin which was prescribed 3 days ago for a spreading dentoalveolar abscess. Which ONE of the following tests below is MOST likely to be abnormal?
A. Raised alanine transaminase
B. Raised alkaline phosphatase
C. Raised creatinine kinase
D. Raised lactate dehydrogenase
E. Raised troponin
3. Since commencing antibiotic treatment, a patient’s INR readings has become raised and shown significant fluctuations. Their medical, drug, and allergy histories are as follows:
Medical history—Atrial fibrillation
Drug history—Warfarin 5 mg daily
Allergy history—Penicillin
Which ONE of the following antibiotics is the MOST likely cause of the patient’s raised and fluctuating INR reading?
A. Azithromycin
B. Cephalexin
C. Erythromycin
D. Trimethoprim
E. Vancomycin
Orofacial manifestations of systemic diseases
4. A young child who is seen regularly in the cardiac department, has learning difficulty, delayed tooth eruption, macroglossia, and characteristic facies. Which ONE of the following BEST describes the patient’s findings?
A. Beckwith–Wiedemann syndrome
B. Cross syndrome
C. Down’s syndrome
D. Myxoedema
E. Simpson–Golabi–Behmel syndrome
5. A patient presents with progressive dysphagia. On examination, there is pallor of the mucocutaneous tissues, and the tongue is denuded of the papilla. The resting pulse is fast and the nails on the hands and feet are either flat or concave in shape. Which ONE of the following syndromes is the MOST likely in this patient?
A. Gardner syndrome
B. Glanzmann’s syndrome
C. Melkersson–Rosenthal syndrome
D. Peutz–Jeghers syndrome
E. Plummer–Vinson syndrome
6. A patient presents with a histor y of increasing obesity and depression. They have noticed a yellow tinge to the colour of their skin and increasing malaise. In addition, they have required their flat to remain heated throughout the year. Which ONE of the following oral manifestations is this patient MOST likely to develop?
A. Macroglossia
B. Median rhomboid glossitis
C. Recurrent oral ulcers
D. Spaced dentition
E. Spontaneous gingival bleeding
7. Skull imaging showed multiple discrete punched-out lesions. Blood tests show a raised erythrocyte sedimentation rate (ESR), hypercalcaemia, and abnormal plasma electrophoresis. Which ONE of the following is the MOST likely diagnosis for this patient?
A. Langerhans’s histiocytosis
B. Metastatic bone disease
C. Multiple myeloma
D. Paget’s disease of the bone
E. Secondary hyperparathyroidism
8. A patient presents glossitis and peripheral sensory paraesthesia of hands and feet. They have had gastrectomy for management of gastric cancer. Which ONE of the following treatments are they MOST likely to benefit from?
A. Blood transfusion
B. Intramuscular erythropoietin
C. Intramuscular vitamin B2
D. Oral ferrous fumarate
E. Oral hydroxocobalamin
9. An overweight teenage girl presents with increasing amount of facial hair. She has a history of late onset of menstruation, secondary amenorrhoea, and recent onset of sleep apnoea. She is currently on metformin. Which ONE of the following is the MOST likely diagnosis for this patient?
A. Cushing’s syndrome
B. Hypogonadism
C. Hypothyroidism
D. Polycystic ovary syndrome
E. Prolactinoma
20. A patient presents to the or thodontist for treatment of a class III malocclusion. Examination reveals prominent supraorbital ridges and bitemporal hemianopia. Intraoral examination elicits increased spacing of the dentition and macroglossia. Which ONE of the following is the MOST likely cause of this patients’ visual defect?
A. Craniopharyngioma
B. Intracranial meningioma
C. Neuroendocrine carcinoma
D. Phaeochromocytoma
E. Pituitary adenoma
2. A child present with oral ulceration and abdominal pain. Examination reveals lip swelling, deep linear ulcers, mucosal tags, and unusual ridging of the buccal mucosa. Blood investigation revealed raised faecal calprotectin (elastase) and inflammatory markers. Which ONE of the following is MOST likely to be the diagnosis?
A. Coeliac disease
B. Crohn’s disease
C. Irritable bowel syndrome
D. Microscopic colitis
E. Ulcerative colitis
22. A patient with multiple maxillary bony exostosis is unable to have upper partial dentures fabricated. He has an annual colonoscopy to monitor intestinal polyps. Which ONE of the following eponymous syndromes BEST characterizes this patient’s findings?
A. Gardner’s syndrome
B. Gorlin–Goltz syndrome
C. Grinspan syndrome
D. Melkersson–Rosenthal syndrome
E. Peutz–Jeghers syndrome
23. A teenage patient presents with multiple basal cell carcinoma-like lesions on the face. They are under review for bilateral odontogenic keratocysts at the maxillo-facial unit. Which ONE of the following eponymous syndromes BEST characterizes this patient’s findings?
A. Albright syndrome
B. Gardner syndrome
C. Gorlin–Goltz syndrome
D. Peutz–Jeghers syndrome
E. Plummer–Vinson syndrome
24. A patient with multiple telangiectatic spots on the lip and buccal mucosa experiences recurrent epistaxis and menorrhagia. Full blood count and peripheral smear revealed slightly low haemoglobin and microcytosis, respectively. Which ONE of the following eponymous syndromes BEST represents the patient’s findings?
A. Angina bullosa haemorrhagia
B. Bernard–Soulier syndrome
C. Osler–Weber–Rendu syndrome
D. Peutz–Jeghers syndrome
E. Sturge–Weber syndrome
25. A patient with multiple pigmented macules on the face and buccal mucosa is found to have polyps on colonoscopy. Which ONE of the following eponymous syndromes BEST represents the patient’s findings?
A. Addison disease
B. Gardener’s syndrome
C. Laugier–Hunziker–Baran syndrome
D. Melkersson–Rosenthal syndrome
E. Peutz–Jeghers syndrome
26. A patient presents with multiple skin nodules and brown spots first noticed during childhood. The lesions have increased in size and number with age. Which ONE of the following conditions BEST fits with these skin manifestations?
A. Addison’s disease
B. Basal cell carcinoma
C. Neurofibromatosis
D. Peutz–Jeghers syndrome
E. Tuberous sclerosis
27. A young boy attends for routine dental review. He is found to have hypodontia with scant fine hair, no eyelashes and eyebrows, and dry skin. Which ONE of the following BEST characterizes this boy’s orofacial presentations?
A. Down’s syndrome
B. Ectodermal dysplasia
C. Ehlers–Danlos syndrome
D. Fibrous dysplasia
E. Pierre–Robinson syndrome
28. A pregnant woman has a localized fleshy red gingival lump between the mandibular left first and second premolars. The lesion bleeds occasionally and first appeared during pregnancy. Which ONE of the following BEST characterizes the oral lesion?
A. Fibrous epulis
B. Giant cell tumour
C. Gingiva hypertrophy
D. Pregnancy gingivitis
E. Pyogenic granuloma
Haematological diseases
29. A patient with a week’s history of sore throat, fever, malaise, cervical lymphadenopathy, and palatal petechiae develops abdominal tenderness. Following an emergency computed tomography (CT) scan which showed an enlarged spleen, they underwent an urgent splenectomy. Which ONE of the following conditions is the MOST likely reason underlying the need for the patient’s splenectomy?
A. Autoimmune haemolytic anaemia
B. Felty’s syndrome
C. Infectious mononucleosis
D. Sickle cell disease
E. Thrombocytopenic purpura
30. An elderly patient with atrial fibrillation has accidentally taken double their normal warfarin dose. Their INR is 9.6 and they have no obvious signs of bleeding. Which ONE of the following is MOST appropriate to manage this patient?
A. Stop warfarin and administer fresh frozen plasma
B. Stop warfarin and administer oral vitamin K
C. Stop warfarin and administer prothrombin complex concentrate
D. Stop warfarin and administer recombinant f actor VIIIa
E. Stop warfarin and monitor INR more frequentl y
3. A patient on warfarin, simvastatin, ramipril, ibuprofen, and bendroflumethiazide requires a tooth extraction. Which ONE of the following special investigations SHOULD be requested before the extraction?
A. Activated partial thromboplastin time (APTT)
B. Bleeding time (BT)
C. Clotting factor assays
D. Full blood count (FBC)
E. Prothrombin time (PT)
32. A patient with haemophilia attends for routine dental care complaining of spontaneous gingival bleeding since his last appointment. You suspect this may be caused by gingivitis. Which ONE of the following bleeding investigation or assays would be MOST appropriate in this circumstance?
