Dental MCQ
Autonomic drugs and dental interactions · Pharmacology · INBDE Patient Cases

Autonomic Pharmacology INBDE Patient Cases

By Dr. Isaac Sun, DDS

8 ADA INBDE-format patient cases on autonomic pharmacology. Each case is a shared patient box (chief complaint, history, medications, allergies, exam) followed by linked multiple-choice questions with full distractor explanations. Practice the way the real exam is structured.

8 patient cases40 linked questionsADA INBDE formatFull distractor explanations

Eight ADA INBDE-format patient cases on autonomic pharmacology: epinephrine plus a non-selective beta-blocker producing a hypertensive response with reflex bradycardia (the classic dental drug interaction), pilocarpine for Sjögren xerostomia through muscarinic M3 agonism, albuterol for an asthma exacerbation chairside and the propranolol caveat, atropine for symptomatic bradycardia and the glycopyrrolate alternative, choosing a vasoconstrictor (epinephrine vs phenylephrine) for a cardiac patient with the 0.04 mg cap, cholinergic crisis from AChEI overdose with the DUMBBELS/SLUDGE picture and atropine plus pralidoxime, anticholinergic polypharmacy as a driver of xerostomia, and rebound hypertension from abrupt clonidine cessation. Topics include alpha and beta adrenergic receptors, sympathomimetics, sympatholytics, parasympathomimetics, parasympatholytics, and the dental drug interactions every clinician needs.

Case Coverage Map
What each case is testing
Epinephrine in a patient on a non-selective beta-blocker:
The dental drug interaction: unopposed alpha-1 vasoconstriction with reflex bradycardia, cardioselective vs non-selective, and the 0.04 mg cap.
Pilocarpine for xerostomia in Sjögren syndrome:
Muscarinic agonism (M3) to drive salivary flow, side effects (sweat, GI), contraindications (asthma, glaucoma, bradycardia), and cevimeline as an alternative.
Albuterol for an asthma exacerbation:
Selective beta-2 agonism to bronchodilate, high-dose tachycardia/tremor, ipratropium contrast, and the propranolol caveat.
Atropine for symptomatic bradycardia:
Muscarinic blockade at the SA node, anticholinergic side effects in the elderly, glycopyrrolate as a peripheral alternative, and atropine + pralidoxime for organophosphates.
Choosing a vasoconstrictor for a cardiac patient:
Alpha-1 vasoconstriction, the cardiac cap (~0.04 mg), phenylephrine as pure alpha-1, deferring unstable angina, and cardioselective beta-blocker safety.
Cholinergic crisis from too much pyridostigmine:
AChEI overdose, the DUMBBELS/SLUDGE picture, atropine as antidote, pralidoxime for organophosphates, and distinguishing from myasthenic crisis.
Dry mouth from anticholinergic medications:
Polypharmacy with anticholinergic burden, classic anticholinergic side effects, fluoride and salivary substitutes, and pilocarpine/cevimeline as rescue.
Clonidine and rebound hypertension:
Central alpha-2 agonism, rebound on abrupt cessation, dexmedetomidine and methyldopa as relatives, and capped epinephrine when stable.
Patient case: Epinephrine in a patient on a non-selective beta-blocker
0 of 5 answered, 0 correct
Patient
Male, 64 years old
Chief Complaint
Needs a posterior molar extraction; takes propranolol for migraine prophylaxis.
Background and/or Patient History
  • Long-standing migraine prophylaxis with propranolol (a non-selective beta-blocker)
  • Otherwise healthy; no history of asthma
  • Needs local anesthetic with vasoconstrictor for an extraction
Allergies
NKDA
Medications
  • Propranolol
Current Findings
  • Patient on a non-selective beta-blocker needing dental local anesthesia
  • Discussion of epinephrine dose and the classic interaction
  1. Question 1
    Hard
    The classic interaction in this patient if a large dose of epinephrine is given is:
  2. Question 2
    Hard
    The mechanism is:
  3. Question 3
    Moderate
    If this patient instead took metoprolol (a cardioselective beta-blocker), the interaction would be:
  4. Question 4
    Moderate
    Practically, the dentist should:
  5. Question 5
    Easy
    This case illustrates that:

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Patient case: Pilocarpine for xerostomia in Sjögren syndrome
0 of 5 answered, 0 correct
Patient
Female, 56 years old
Chief Complaint
Severe dry mouth and recurrent caries; recent diagnosis of Sjögren syndrome.
Background and/or Patient History
  • Sjögren syndrome with severe xerostomia
  • Recurrent root surface and cervical caries despite topical fluoride
  • Dental team initiating pilocarpine after medical review
Allergies
NKDA
Medications
  • Pilocarpine (initiated)
Current Findings
  • Severe xerostomia from Sjögren syndrome
  • Discussion of cholinergic stimulation of saliva
  1. Question 1
    Moderate
    Pilocarpine increases salivary flow by:
  2. Question 2
    Moderate
    Expected side effects of pilocarpine include:
  3. Question 3
    Hard
    Pilocarpine is relatively contraindicated in:
  4. Question 4
    Moderate
    An alternative agent for the same indication is:
  5. Question 5
    Easy
    Beyond pharmacologic stimulation, dental management of Sjögren xerostomia includes:

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Patient case: Albuterol for an asthma exacerbation
0 of 5 answered, 0 correct
Patient
Male, 22 years old
Chief Complaint
Acute wheezing during a routine restorative appointment.
Background and/or Patient History
  • Asthma, well controlled at baseline; carries a rescue inhaler
  • Wheezing begins during the procedure
  • Patient uses two puffs of his albuterol inhaler
Allergies
NKDA
Medications
  • Albuterol inhaler (rescue)
Current Findings
  • Acute mild asthma exacerbation chairside
  • Beta-2 agonist rescue therapy
  1. Question 1
    Easy
    Albuterol relieves bronchospasm by:
  2. Question 2
    Moderate
    At high doses, albuterol can lose selectivity and cause:
  3. Question 3
    Moderate
    Ipratropium relieves bronchospasm by:
  4. Question 4
    Hard
    If this patient were also on propranolol, dental and respiratory care would be complicated because:
  5. Question 5
    Easy
    After the exacerbation resolves, dental care should:

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Patient case: Atropine for symptomatic bradycardia
0 of 5 answered, 0 correct
Patient
Female, 72 years old
Chief Complaint
Develops symptomatic bradycardia during a dental appointment.
Background and/or Patient History
  • Vasovagal response with sustained bradycardia and lightheadedness
  • Vital signs: HR 38, BP 88/52
  • Emergency kit accessed; atropine considered
Allergies
NKDA
Medications
  • None notable
Current Findings
  • Symptomatic bradycardia, vasovagal pattern
  • Indication for atropine
  1. Question 1
    Moderate
    Atropine raises heart rate by:
  2. Question 2
    Moderate
    Atropine's side effect profile in the elderly includes:
  3. Question 3
    Hard
    An alternative anticholinergic without central effects is:
  4. Question 4
    Moderate
    In organophosphate poisoning, atropine is paired with:
  5. Question 5
    Easy
    This case illustrates that atropine is:

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Patient case: Choosing a vasoconstrictor for a cardiac patient
0 of 5 answered, 0 correct
Patient
Male, 70 years old
Chief Complaint
Routine restorative work in a patient with recent unstable angina.
Background and/or Patient History
  • Coronary artery disease with recent unstable angina (now stable on optimal medical therapy)
  • Needs a routine restorative procedure
  • Discussion of vasoconstrictor choice and dose limit
Allergies
NKDA
Medications
  • Aspirin
  • Metoprolol
  • Atorvastatin
Current Findings
  • Stable cardiac patient needing local anesthesia
  • Vasoconstrictor selection discussion
  1. Question 1
    Moderate
    Epinephrine in dental local anesthetic acts mainly as a vasoconstrictor through:
  2. Question 2
    Moderate
    In a cardiac patient, the safe epinephrine cap is approximately:
  3. Question 3
    Moderate
    Phenylephrine differs from epinephrine in that it:
  4. Question 4
    Moderate
    Routine elective dental work in a patient with recent UNSTABLE angina should:
  5. Question 5
    Hard
    On metoprolol (a cardioselective beta-blocker), the dental epinephrine interaction is:

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Patient case: Cholinergic crisis from too much pyridostigmine
0 of 5 answered, 0 correct
Patient
Female, 48 years old
Chief Complaint
Profuse salivation, lacrimation, diarrhea, and weakness; on pyridostigmine for myasthenia gravis.
Background and/or Patient History
  • Myasthenia gravis on pyridostigmine
  • Recently increased her dose because of perceived fatigue
  • Now with the picture below
Allergies
NKDA
Medications
  • Pyridostigmine (recently increased)
Current Findings
  • Profuse salivation, lacrimation, urination, and diarrhea
  • Bronchorrhea, bradycardia, miosis
  • Cholinergic crisis from AChEI overdose
  1. Question 1
    Moderate
    Pyridostigmine is an acetylcholinesterase inhibitor (AChEI) that:
  2. Question 2
    Moderate
    The signs of cholinergic crisis (DUMBBELS / SLUDGE) include:
  3. Question 3
    Hard
    Acute management of muscarinic excess is:
  4. Question 4
    Moderate
    If this were organophosphate poisoning instead of an AChEI overdose, treatment would also include:
  5. Question 5
    Hard
    Distinguishing cholinergic crisis from myasthenic crisis can be done by:

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Patient case: Dry mouth from anticholinergic medications
0 of 5 answered, 0 correct
Patient
Female, 70 years old
Chief Complaint
Chronic dry mouth and cervical caries; on multiple medications.
Background and/or Patient History
  • Overactive bladder treated with oxybutynin (anticholinergic)
  • Allergic rhinitis treated with diphenhydramine at night (anticholinergic effect)
  • Tricyclic for chronic pain (anticholinergic effect)
Allergies
NKDA
Medications
  • Oxybutynin
  • Diphenhydramine
  • Amitriptyline
Current Findings
  • Polypharmacy with cumulative anticholinergic burden
  • Xerostomia and cervical caries
  1. Question 1
    Moderate
    Each of this patient's drugs decreases saliva by:
  2. Question 2
    Moderate
    Other classic anticholinergic side effects in this patient include:
  3. Question 3
    Moderate
    Dental management includes:
  4. Question 4
    Moderate
    A pharmacologic option to stimulate residual salivary flow (after physician review) is:
  5. Question 5
    Easy
    The teaching point is that the medication list is:

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Patient case: Clonidine and rebound hypertension
0 of 5 answered, 0 correct
Patient
Male, 58 years old
Chief Complaint
Severe hypertension after running out of clonidine for several days.
Background and/or Patient History
  • Long-standing hypertension on clonidine
  • Ran out of medication for 3 days
  • Now with severe hypertension and a racing pulse
Allergies
NKDA
Medications
  • Clonidine (recently missed)
Current Findings
  • Severe hypertension after abrupt clonidine cessation
  • Discussion of central alpha-2 agonism and rebound
  1. Question 1
    Hard
    Clonidine lowers blood pressure by:
  2. Question 2
    Hard
    Abrupt cessation of clonidine causes:
  3. Question 3
    Moderate
    Other central alpha-2 agonists include:
  4. Question 4
    Moderate
    Elective dental care in this patient should:
  5. Question 5
    Moderate
    Once stable, the dental dose of epinephrine should be:

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Autonomic Pharmacology core recall

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